nos-trum. pronunciation: \nos'-trum\. noun. Etymology: Latin, neuter of noster our, ours.
1. a medicine of secret composition recommended by its preparer but usually without scientific proof of its effectiveness.
2. a usually questionable remedy or scheme.
See here for more discussion.

Thursday, April 22, 2010

Does "Allocation Of Scarce Resources" = "Death Panel"?

Medical Ethics under Constraints:  There's no area of human need or desire that is not subject to resource limits.  Managing an ever-increasing demand in the face of resource limits may prove impossible.

Consider this:  patients want the best medical care available They don't care whether the latest, expensive care provides only a small benefit.  In times of duress, or serious illness, they don't even care whether we know for sure yet that the new treatment IS beneficial.  If other modalities have been exhausted or the threat is lethal, they want it.  Now.

There have been reams of discussion by policy wonks on how to put limits on what can be provided.  Much of that discussion has centered on how we quantify the value of a human life, particularly in comparison to the lives of others.

Ethics experts have sometimes pointed to the process of triage in medical disasters, saying that the situations are similar.  But note this critical point:  when I make a decision to treat one patient over another in a disaster, a judgment is being made between treating patients with critical injuries who can quickly be saved versus a patient with a potentially lethal injury who may not survive and who requires a great deal of time to treat.  No judgment is made about the value of the person's life to herself/himself, others, or society.

Those same ethics professionals have tried to come up with ways to make decisions over who gets medical care when the situation is not time-limited, but resource-limited.  If there's only so much antibiotic to go around, and we have time to get the supply to those in need, what individuals do we choose?

The answers to this question have been varied.  One of the most prominent, proposed by a medical ethics expert, Dr. Ezekiel Emanuel (see here in The Lancet medical journal, Jan 31, 2009), is to establish a "complete lives" value system.  In simplistic terms, the decision to treat will revolve around the potential of the individual for a full life ahead of them.  That is, it "prioritizes young people who have not yet lived a complete life..."

This is the graph Dr. Emanuel published in the article. It lays out the "Age-based priority for receiving scarce medical interventions under the complete lives system:"

Note, that when you reach 50, the probability of receiving care under conditions of scarce resources falls, with those over 70 being least likely to receive care.   They have lived "a complete life" and should not compete equally with a 20 year old.

The question of young children is addressed by consideration of how much society has invested in a life: 
Adolescents have received substantial education and parental care, investments that will be wasted without a complete life. Infants, by contrast, have not yet received these investments.
Hence, an infant would be valued less than a toddler, a toddler less than an adolescent.

All of this seems cold and bloodless, but it should be mentioned that Dr. Emanuel and his co-authors were not talking about Death Panels and such nonsense.  The focus of their paper was NOT on those situations where money is the resource limitation, but supply:  such as the stocks of Cipro during an anthrax attack.

However, you can see where the scheme can be extended from a supply situation such as "stocks of antibiotics" to a supply that is monetary in nature.  If society can't afford to give everybody dialysis--or some cutting edge new therapy that "could" be lifesaving for a few (who we can't identify in advance) but of minimal benefit to most--then some justification must be made for who gets taken care of.

You may be surprised to know that in dialysis these decisions have been made for decades.  Young adults are prioritized over older adults when the number of dialysis units is limited.  Is that a Death Panel?  Not really, but it's not a level playing field, either, and older patients in need do their detriment and risk of loss of life.

Think this is the way we should go?  In Great Britain, a single-payer government health care system, there is a formula:  this much money for each year of life--exceed that and we won't pay.  That's another approach; is that the best way?

To relate this discussion back to US politics and health care reform, it's fascinating to note that Dr. Ezekial Emanuel is the brother of the White House Chief of Staff, Rahm Emanuel, and is an advisor to President Obama on health care reform.  Lastly, recall the President's answer (which I'm paraphrasing) to a question in a Town Hall last year from a woman who was concerned that her mother of 80 years would not receive a hip replacements:  "Well, maybe taking pain medicines instead is the best answer."

Funny how things are connected.

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