The Goals of a Healthcare System, by Benjamin Jacobson

The Goals of a Healthcare System, by Benjamin Jacobson

How can we improve healthcare and attain the best possible system of medical care? This is a quite difficult question in its own right, but attempts to answer it are further impeded by the fact that we must first qualify what an improvement is and develop a clear concept of what the goals of a healthcare system should be.

At its core, it seems simple enough to state that an ideal healthcare system provides the best possible healthcare to the most possible people. When taken to the extreme, this would be a system in which every person in need of care receives all of the care that they need. Yet everyone understands that such a thing would be impossible. Healthcare, like all industries, must deal with scarcity. One potential response to such an issue would be to approach healthcare purely economically. Prices would rise and healthcare would go only to those wealthy enough to pay for it. Yet once again most would agree that such a thing would be unjust and unacceptable. Thus healthcare must approach its scarcity with moral values, and an ideal healthcare system would be one that ethically distributes care to those in need.

So how does one go about ethically allocating resources? It becomes quickly evident that such a thing must be conducted on a large scale basis rather than considering allocation on a case by case basis. Consider two patients requiring treatment for lung cancer, while a shortage has left a hospital with only enough drugs for one. If only one was a smoker, one might assert that the other was more deserving of care, as he didn’t bring his illness on himself to the extent that his fellow patient did. While this may seem reasonable, suppose the smoker has a wife and three children while the other patient lives alone. Suddenly the situation is less black and white. A case by case allocation system quickly becomes infinitely complex, and requires one to qualitatively value lives. This valuation of lives was prominent in the news in 2009 when ex-governor Sarah Palin asserted that the Affordable Care Act would lead to the establishment of government “death panels” who would decide who was worthy of treatment and who would be left to die. This claim was eventually debunked, and was named Politifact’s 2009 Lie of the Year [Angie Drobnic Holan, 2009]. Despite this, Palin was not wrong in all regards, and the public response to her claim provides valuable insight into the viability of such a system. Palin believed that a system that promised healthcare to everyone would have to ration that care. This is a valid assumption, and is in fact the assumption that has driven us to explore ethical allocation in the first place. Where she strayed was in assuming this allocation would be carried out by a so called “death panel”. As will be explored below, there are certainly other approaches. Finally, the enormous public outcry in response to Palin’s claim demonstrates that even if a case by case allocation system were not, as was demonstrated with the lung cancer anecdote, infinitely complex, any system that qualitatively values lives could never be politically viable.

A potentially better approach would be to adopt a utilitarian policy on healthcare allocation. That is, the goal of the system is simply to maximize the number of lives saved or patients cured. Refining this, one could attempt to maximize Quality-Adjusted Life Years (QALY), a measure that scales years of life based on health during those years [Zeckhauser and Shepard, 1976]. A perfectly healthy year counts as one QALY, and death as 0, with all medical conditions falling in between.  The greatest drawback to QALYs is that they rely on value being assigned to various health conditions and on the population accepting these valuations as fair. How can such a thing be accomplished? The standard gamble method consists of asking people given a certain condition whether they would undergo a procedure or not if the procedure had an X% chance of succeeding and would otherwise result in death. The value X at which one would be indifferent about receiving treatment would be used to ascertain the value of the condition with respect to QALYs. The time trade-off method asks people to choose between living a set numbers of years with a condition or a variety of shorter periods of time in perfect health. Once again, the indifference point is used to value the condition [Whitehead and Ali 2010]. With either of these methods, a large number of people would need to be surveyed and their results aggregated to develop a representative valuation. Though the determined valuations would not satisfy everyone, they would be the best representation of the population for a utilitarian method that looks only at the population as a whole. Though the case by case qualitative method mentioned in the lung cancer anecdote does differ from this more quantitative approach, it remains true that case by case systems are prohibitively inefficient in systems as vast as allocating healthcare to entire populations. Thus we establish QALYs as an aggregated valuation representative of the general population, and desire through our allocation to maximize QALYs of our population. Though this measure was originally developed for comparing the cost-effectiveness of resource allocation across healthcare programs, it can be a valuable tool not just monetarily, but in maximizing the overall good of a healthcare system.

It is here, however, when everything seems to be tidied up, that we encounter our greatest problem. If our system is truly utilitarian, then there should be no qualms about pulling someone off of the street and harvesting their organs in order to save multiple patients in need of transplants. Most would agree that such a thing is obviously wrong and immoral, however. In China, death row inmates are often forced to donate their organs, a practice that has been met with considerable backlash [Tatlow, 2015]. Given such moral reprehension to death row harvesting, one can only imagine the public outcry if average civilians were forced to donate organs. The utilitarian approach, then, must be revised. But how so? I propose that healthcare follow a more deontological approach. Such a theory requires that we must qualify our desire to maximize QALY with the rule that we can do no harm. Such an idea has been present for many years, and in fact appears in the classical Hippocratic Oath: “…I will abstain from all intentional wrong-doing and harm, especially from abusing the bodies of man or woman, bond or free.”

In deontology and other philosophical codes, the next step after do no harm would be a duty to rescue. Essentially, if you were to see someone drowning and did not swim out to save them, that would be equivalent to you actually throwing them into the water in the first place. Implementing this duty to rescue in healthcare systems presents a serious problem however. Given scarce resources it is impossible to rescue everyone, and thus there are some who do not receive proper treatment. In a sense this is passive harm. Patients may not be unwillingly losing organs, but by being selected not to receive treatment, they are undoubtedly being harmed. As such, mandating a duty to rescue contradicts a do no harm philosophy, and we are left right back where we started. This means that should we accept a do no harm approach, we cannot fully implement a duty to rescue. There is obviously an expectation to rescue if possible, as demonstrated by our desire to maximize QALY, but the result is that we place the value of maximizing QALY above that of minimizing passive harm.

These philosophical issues are incredibly complex, and much more nuanced than the path I have taken to arrive at this point. To claim that attempting to maximize QALY while doing no (active) harm would result in an idealized healthcare system would be a gross simplification, if not flat out incorrect. However, I do see valuable implementations of these constraints on a smaller scale. One major issue faced by hospitals is severe shortages of particular drugs. Due to regulation requirements and the desire of efficiency by manufacturers, many drugs are produced entirely in one or two locations, rather than in scattered factories across the country and the world. This means that malfunctioning equipment or contamination can easily devastate the entire global supply of a drug [Ventola, 2011]. When faced with a shortage, a hospital must quickly decide how to distribute the supply it has to the patients in need. It in is these specific, time pressed, and high pressure situations that a QALY maximizing do no harm policy can shine. Such a thing could be significantly aided by available technology. The first step would be for doctors and ethicists to begin compiling a comprehensive database of conditions, treatments, and associated QALY costs. There exist currently algorithms for solving many problems similar to this one. These algorithms consider the costs of all of their options and strive to find an optimal solution given these costs. By refining our understanding of QALYs and constructing a good algorithm to utilize this data, hospitals would be able to quickly find good solutions to their small scale scarcity problems by feeding the computer their available drug supply and the patients in need. Such algorithms could even be expanded to consider the use of replacement drugs, which may be less effective, or potentially equally effective for some patients but not others. While it is never easy to make decisions that preclude some from receiving optimal care, there are times when such decisions must be made. By having a concrete approach to such situations, hospitals avoid an ethical minefield and emerge having maximized QALYs without actively harming anyone. It is impossible to prove that a philosophical idea is correct, but the concreteness and efficiency of this QALY maximizing strategy are unquestionably present, and the results it produces are arguably as just and desirable as one can attain.

 

 

Angie Drobnic Holan. “PolitiFact’s Lie of the Year: ‘Death Panels.’” PolitiFact. N.p., 18 Dec. 2009. Web. 9 May 2016.

Tatlow, Didi Kirsten. “China Bends Vow on Using Prisoners’ Organs for Transplants.” The New York Times 16 Nov. 2015. NYTimes.com. Web. 6 May 2016.

Ventola, C. Lee. “The Drug Shortage Crisis in the United States.” Pharmacy and Therapeutics 36.11 (2011): 740–757. Print.

Whitehead, Sarah J., and Shehzad Ali. “Health Outcomes in Economic Evaluation: The QALY and Utilities.” British Medical Bulletin 96.1 (2010): 5–21. bmb.oxfordjournals.org. Web.

Zeckhauser, Richard, and Donald Shepard. “Where Now for Saving Lives?” Law and Contemporary Problems 40.4 (1976): 5–45. JSTOR. Web.

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