Topic	Introduced in chapter
Hippocratic oath	1
A caring response	2
Moral agent	3
Moral distress	3
Ethical dilemma	3
Principle of beneficence	4
Principle of justice	4
Deontology/duty reasoning	4
Rights	4
Utilitarian reasoning	4
Medical futility	14
Extraordinary (heroic) care	14

Introduction

As this book goes to press, the United States legislature and public have again been embroiled in a health care reform debate. Among the issues are whether health care is a right and whether we have a responsibility to care for persons who are not in our immediate circle of intimacy and relationship.

All nations face questions of limited health care resources and escalating costs. These issues worldwide create ethical challenges that involve the allocation of health care resources. Allocation is a term that suggests intentional decisions about how a good is distributed. In ethical deliberation, such challenges fall within the category of distributive justice, the topic of this chapter, and compensatory justice, discussed in Chapter 16.

Distributive justice purports that humans have the capacity to make nonarbitrary, reasonable bases for distributing goods and services that are in at least moderately scarce supply but desired by many. For our purposes, health care resources are those goods and services. Some justice issues are best addressed by examining your direct care giving role. For example, you may be faced with a personnel shortage in your workplace and will have to decide where to cut corners and why. You may work where there is not enough equipment or space or money to fully satisfy what your best effort requires. In operating under that extenuating circumstance, you are forced to make decisions about how to spread out the desired good or service. In society, claims for goods are taken into account according to individuals or groups of people who are judged to be similarly situated according to need, merit, or other considerations. The resulting decisions about who gets what are termed microallocation decisions.

Some of the most critical issues regarding allocation of resources also remove you from the arena of direct patient care to considerations of policy, where whole groups of similarly situated people are implicated. For instance, in the United States and globally, current lively policy debates surround such issues as how to distribute limited supplies of medicines for treatment of AIDS, immunizations in times of epidemics or pandemics (e.g., for new strains of flu), and organs for organ transplantation.

Reflection

To help you reflect on the concept of distributive justice, consider the following question. Do you think a person whose liver has been damaged by alcohol or other substance abuse should have the same chance for a transplant as someone whose equally serious liver damage was caused by other reasons and not by self-destructive behaviors? Yes____ No ___

Why? If yes, make a list of any conditions you would impose on the substance abuser and supports that should be in place to ensure that he or she would not end up in the same situation again, knowing that the success rate depends in part on abstinence after the transplant. If you think no, he or she should not be given exactly the same priority as anyone else with similar medical need, take a minute before reading further to write down some reasons why you feel this way.

_____________________________________________________________

Currently, in most countries where liver transplants are offered, there is a waiting period for alcoholics to demonstrate that they are successfully abstaining from alcohol, a criterion that appears to reduce the recidivism rate among those fortunate enough to be chosen for an organ. This wait is above and beyond the wait that other similarly needy potential organ recipients experience. Whatever the outcome, the decision about organ transplantation points out that in the allocation of health care resources conscious choices are made, and the choices do make a difference in the lives and well-being of whole groups of similarly situated people.1

Summary

Distributive justice helps us find morally justifiable criteria for the distribution of desired and needed resources. Microallocation debates regarding the priority list for allocation of scarce resources revolve around considerations of need and likelihood of benefit and often include considerations of lifestyle.

Some policy decisions require that different types of societal goods be compared, recognizing that a society does not have infinite resources to cover all of them. For instance, such allocation decisions may involve trade-offs between more roads being built, or military installations provided with better facilities for troops, or existing national parks maintained. These judgments are called macroallocation decisions. Although these decisions are extremely important, we leave this aspect of your study to other courses.

For your discernment about distributive justice, the following story will assist you in your thinking about your role in these complex practice and policy issues.

The Story of Christopher Lacey and the Contenders for His Bed

One Monday morning, as John Krescher, a critical care nurse specialist, is going into the intensive care unit (ICU), he is stopped by Mr. Christopher Lacey’s sister, a nurse. John often has seen her and her husband at her brother’s bedside, although he has not had any lengthy discussions about Christopher with them. This morning, Mr. Lacey’s sister says angrily that Christopher’s attending physician, Dr. Sidney McCally, is planning to transfer her brother prematurely to the general medical unit. She believes it is because Dr. McCally is being urged to do so by the hospital utilization committee and the case manager for Mr. Lacey’s medical coverage plan. She and her husband are threatening a lawsuit against the hospital unless her brother is allowed to remain in the ICU and receive what she believes is optimal medical care for him there. John expresses his surprise and is about to ask her some further questions, but she rushes out of the unit, apparently on the verge of tears.

John goes over to Christopher Lacey’s bedside and puts his hand on the man’s shoulder. He studies the patient’s face for some sign of response, but there is none. John’s mind is flooded with thoughts. Mr. Lacey is a 28-year-old, divorced postal employee with no children. “He is only a year older than I am,” John thinks. Initially, Christopher was admitted to the hospital with severe, acute abdominal pain. After several days of tests that yielded no clues, the physicians did an exploratory laparotomy.*

At that time, an ischemic segment of bowel was resected. In the postoperative suite, Christopher experienced respiratory arrest for reasons the doctors could not explain and was transferred to the ICU under Sidney McCally’s care. Since that time, 3 weeks ago, his condition has been fluctuating neurologically and he has never fully regained consciousness.

In fact, Christopher Lacey has had a stormy course characterized by multiple serious medical complications. A systemic infection developed immediately after surgery, at which time it was thought he would die. He was treated with massive doses of antibiotics and appeared to be recovered. But the antibiotics were severely toxic to his kidneys. He now shows signs of kidney failure, which may necessitate renal dialysis.

Some members of the health care team have become progressively more pessimistic about Christopher Lacey’s prognosis. In the ICU rounds 2 days ago, Sidney McCally shared with the ICU nursing staff that she had had several discussions with the patient’s sister and had tried to explain to her the likelihood that his condition would not improve. “But,” Dr. McCally said, “she and her husband wish aggressive treatment as long as there is any hope of meaningful recovery or survival.” Mr. Lacey had left no living will or durable power of attorney and had never expressed an opinion about long-term life support.

John goes back to the ICU desk where his colleague, Janet Cumming, is at the computer entering data in the patient’s medical record. Janet says, “Mr. Lacey’s sister is so upset because Dr. McCally has decided to discontinue intensive care therapy despite the family’s objections. I guess we will be transferring him back to the regular medicine unit later today. Of course, we are 100% full, so I can see why there is a push to get him out, but I question if he is being ousted from us before he is ready.” Janet then adds, “Actually, the situation is worse than you think. We have three people in this hospital on the ICU waiting list, all of them at risk of dying soon if we cannot open up any of our ICU beds for them.”

The goal: a caring response

Discerning a caring response in situations of distributive justice creates special psychological and ethical challenges for health professionals. Many bioethicists have suggested that the demands of justice and care are at odds with one another. In his recent assessment of the challenge, ethicist Leonard Fleck 2 places his hope on the democratic process in a society that has both justice and caring as two of its founding values and assumptions. We take that more optimistic approach in this text, based on reasons we describe in more detail, and invite your own reflection and conclusions. If Fleck and we are correct in embracing the good news that we can arrive at a caring response while taking microallocation decisions into account, the task is to apply our clinical and ethical reasoning about what is best for an individual patient from the perspective of also acknowledging the overall resources available. This does not only include reimbursement limits for services offered to the patient but also limits in your own energies, clinic schedule-imposed limitations, availability of clinical modalities or professional expertise, and space. The strength of this perspective is that it keeps us crisply cognizant of what can best be done within the reality of human limitations. It uses all aspects of a health professional’s clinical reasoning discussed previously in this text, with a balance of procedural, contextual, and interactive elements of the situation. Take the story of Christopher Lacey, his family, and their health professions team. A seemingly healthy younger man becomes a victim of a series of events that leave him in a coma and dependent on extensive medical life supports for his life and sustenance. What should be done for this man whose condition shows no improvement and seems to be getting worse? On an individual patient basis, a widely recognized goal for health professionals is to do whatever is clinically and ethically best. In this story, the entire team understandably has been working to ensure that Christopher Lacey is receiving the most caring response consistent with the professional skill that each is able to provide. It is what we expect of the health professional and patient relationship.

But this chapter confronts you squarely with the reality we often are facing as moral agents: namely, that what we actually can offer him threatens to fall short of the optimum. In the story as we have it, Dr. McCally has not clearly indicated her reasons for wanting to move him out of the ICU to a general medical unit, but we do not have reason to believe that this physician has a less than pure intent. Maybe she is being pushed by the bed utilization committee of the hospital because his medical coverage no longer will support ICU level treatment, or maybe she judges deeply that a disproportionate amount of extremely expensive life support measures are being expended on him in view of his serious prognosis. She may be haunted by the knowledge that three other patients who may benefit more from ICU interventions are waiting in the wings for a bed to clear. All of these reasons fall within the purview of justice considerations that this team is facing. You can again rely on the six-step process of ethical decision making as a tool to assess ethical problems that arise when viewed through the lens of distributive justice.

The six-step process in microallocation decisions

Of the many issues involved in this situation, consider the following issues that are related to the broad questions of allocation of health care resources directed to a single patient:

• Should care be continued in the ICU for patients whose progress is uncertain (e.g., whose conditions may worsen if they are transferred out but do not seem to be getting any better in the ICU)?

• Should patient care be continued in the ICU because the family has a right to require continued treatment of this sort?

• Mr. Lacey’s regimen is based on pooled data derived from many other people in his health plan who were in circumstances similar to his. Should Mr. Lacey be transferred out because his health plan dictates that he has used up his fair share of the plan’s resources?

• Should his financial situation be a factor at all in whether he is kept in the ICU?

In recent years, the direct relationship between health professional and patient has become strained by institutional constraints, some of which were addressed in Chapter 8. Traditional health care ethics, with its emphasis only on the private transaction between you and the patient, often has not addressed the larger institutional questions. For instance, nothing in the Hippocratic Oath, or even in most professional codes of ethics today, provides guidance for how to distribute health care resources fairly and equitably. The challenge is heightened when the allocation involves a scarce resource.

Summary

Traditional professional ethics codes and oaths have not addressed the question of how to distribute scarce resources ethically. The emphasis has been largely or solely on the individual patient.

Step 1: gather relevant information

Patients such as Christopher Lacey bring the troubling aspects of resource allocation keenly into focus. Costs are often a major consideration; let us assume that is the case here. Although, as Chapter 14 suggests, it is possible to keep many clinically compromised people alive almost indefinitely, the reality in most Western countries is that the technology needed to keep patients on life supports is extremely expensive. Callahan³ makes the argument that it is in fact the high cost of medical technology that makes our current health care system unsustainable. He notes: “In a rare instance of consensus, health care economists attribute about 50% of the annual increase in health care costs to new technologies or to the intensified use of old ones.”³ One complicating factor is uncertainty about whether Mr. Lacey’s condition will deteriorate further if he is removed from the ICU, although it appears to his nurse, sister, and at least a couple members of the team that it may. We do not know for sure, but in most cases, we can safely assume that the treatment he needs is out of reach for his family financially. Therefore, most the benefits Mr. Lacey derives from treatment inevitably are at the expense of pooled financial resources in the form of revenue from taxes, insurance premiums, and other common funds. Of course, Mr. Lacey has worked since he was 16 years old, so he also has contributed to some of these pooled funds over the years. That too should be taken into account. Even if insurance denied this level of ICU care but the family could pay the full amount, other justice considerations are facing the professionals.

The limited number of ICU beds is one such consideration. We do not know the full clinical status of the patients in line for the ICU bed currently occupied by Christopher Lacey, but on the basis of John’s concern, they are patients who are in equally clinically compromised situations. It does not appear in this instance that professional staff or medical equipment and supplies are in short supply to compound the allocation challenge.

When viewed from the standpoint of one person’s situation in relation to another (i.e., Mr. Lacey’s need for the ICU compared with Patient B), the allocations considerations draw on ideas of fairness. When a whole group of patients (Group A with, for example, AIDS) is compared with another group of patients (e.g., Group B has diabetes), the justice considerations draw on ideas of equity. We examine each briefly.

Fairness considerations

An understanding of what often is called the principle of fairness in justice discussions requires us to explore two issues raised by Mr. Lacey’s situation.

“First come, first served” and procedural justice.

First, there is the idea of “first come, first served.” As we noted, the resources Mr. Lacey needs may keep someone else from receiving this valued, life-saving therapy in the ICU. Generally speaking, once a patient is in an ICU, he or she will not be removed for another similarly situated person who comes along afterward. Fairness considerations often rely on this culturally derived “first come, first served” idea as a device of arbitration. The assumption is that there is something in the nature of the procedures we adopt that may have a moral prescription in them. Such is the case here. Our procedures for determining who gets priority attention in a queue (when everyone’s need or desire is judged to be the same) is understood to lend insight into the deeper aspects of an overall just society. In the United States and most Western cultures, the procedural justice rule is accepted whether queuing up for an ICU bed, standing in line for concert tickets, or taking a number at a deli counter. If you happened to get there first, it constitutes a moral claim on the spot, something like a “squatter’s right.” You can see how this rule can help to mitigate constant bickering over a resource that would equally benefit many who want or need it.

There is a caveat here. While “first in line” covers a lot of people who present for health care services, it is not always the case. As Western countries become more diverse ethnically and in other ways, the idea of who should have top priority may fall to the eldest, to males, to tribal leaders, or to others, not to whoever happened to get there first. In each case, however, the procedural justice idea that the person with top priority should be able to remain in place seems to hold.

The identified one versus the as-yet-unidentified many.

Consider a second type of fairness issue. Theoretically, resources that Mr. Lacey is using to be sustained in his bodily functions could be channeled into other kinds of programs that could save the lives of hundreds or at least improve their level of well-being (e.g., in screening or immunization programs).