1. The financial, social worth, and medical factors
1. Explain the financial, social worth, and medical factors that influence how organ
transplants are awarded.2. Contrast the American and British ways of rationing health
care.a. What are the benefits and weaknesses of each?b. In which system is it ethically easier
for a physician to say “ no” to a request for expensive treatment? Why?c. Which system do
you think is the most ethical and why? There was a time not long ago when doctors could
offer only limited help, but they dispensed that help generously to their patients. Today,
doctors have amazing medical resources, but they are limited in supplying them by scarcity
and economics. How, for instance, do they decide whether a patient gets a liver transplant?
First, they have to determine if the patient is a good candidate for organ transfer. Then they
have to locate a liver donor or apply to an organregistry. They also have to consider how the
surgery will be paid for since they will need approximately $100,000 to cover the
expense.What should doctors do? Should they follow the market approach and allot
treatment to those who will pay the most for it? Should they decide on the basis of medical
need? Should they depend on a committee to make the decision? Should they depend on a
lottery system or an HMO to make decisions regarding allocating treatment? Or should they
follow the customary approach, which is a bunch of practices that mask the fact that
treatment is being rationed? Eachof these approaches has its advantages and
disadvantages.The market approach is consonant with the free market economy. It
simplifies the choice because the transplant goes to those who can pay for it, either with
their own money or with insurance. Many libertarians feel comfortable with this idea
because people would get the care that they have earned and deserve. Many of us would be
troubled if society followed this option exclusively. It is, however, a component of the
customary approach discussed below.The medical-need approach would allot organs by
giving priority to patients who most need them to stay alive. It would be supported by a
prognosis on the patient’ s likelihood of recuperating to live a healthy life. According to
medical need, a 93-year old man who would almost certainly die with a transplant would
have priority over a 30-year old woman who could live for six months without a transplant.
According to medical prognosis, the woman would receive the transplant.The lottery
approach is another simple approach to rationing transplants that guarantees a kind of
fairness because it treats all seekers of expensive and scarce treatment equally.
This approach may be too simple because it does not take into account the seriousness of
need, the likelihood of success, the length of time on a waiting list, or the person’ s age or
importance to their families and society. On the other hand, everyone would have an equal
2. chance of receiving treatment.The committee approach merely moves the decision making
from a doctor to acommittee without dealing with underlying ethical concerns. The
committee is likely to reflect the arbitrary biases of its members. It does, however,
distribute feelings of guilt and gives its members a feeling of justification because one’ s
judgment is supported by one’ s peers. The customary approach, on the other hand, offers
some comfort to the medical establishment. It conceals the reality that people are denied
treatment because of rationing and conceals reasons ofeconomics and bias that shape the
rationing. In short, it does not rock the medical status quo.For these reasons, the customary
approach will remain in place with only minormodifications until situations, interest
groups, and individuals mount campaigns for more transparency. This is the ordinary
course of democracy: Elites make decisions for their own benefit until people make them
decide for the benefit of ordinary people.One practical decision-making strategy for
allotting organ transplants or other scarce and/or expensive procedures is an explicit or
implicit checklist. Using such checklists, doctors, committees, and HMOs automatically
disqualify certain groups of people from receiving them.Such people might be excluded on
the basis of: age, criminality, drug or alcohol abuse, mental illness, likelihood of medical
failure, quality of life, low social standing, or lack of insurance.Carl Cohen (as cited in Card,
2004) argues that there are no special reasons that should automatically deprive alcoholics
of liver transplants, a position with which many Americans disagree as evidenced by the
furor that erupted when Mickey Mantle, an alcoholic, got a liver while those who had not
been alcoholics went without. Daniel Callahan (as cited in Card, 2004) argues that scarce
treatments should not be allocated to people who have completed theirproductive life spans
because society owes people a good life, not a long life, and because giving old people those
treatments will deprive younger people of opportunities for a full life. He believes that old
age is meant to be a time of reflection and making peace with inevitable death.George Annas
(as cited in Card, 2004) considers ideas for deciding between prostitutes,playboys, poets,
and other reprobates. He says the process should be “ fair, efficient, andreflective of
important social values” (p. 458). He believes that the initial screening should be based
exclusively on strict medical criteria. The secondary criteria should minimize social
worthcriteria and move toward a randomized method of selection, for which he prefers a
modified “ first come, first served” procedure. For example, every prospective kidney
recipient would first be typed with prospective donated kidneys on the basis of
compatibility and likelihood of successful outcomes. After the first selection had been
completed, the prospective recipient whohad been on the list the longest would be awarded
the transplant.On controversial measures of distributive justice, such as the allocation of
medical resources, conflicting moral and economic stances prohibit our assuming any
common moral consensus. Rational ethical consensus needs to be constructed with careful
attention to all points of view and the details of particular situations. General ethical
considerations must be balanced against each other in making such decisions. For these
reasons, an ethics committee composed of broadly represented stakeholders should
probably be consulted in the allotment of scarce medical resources. In such a committee,
political considerations would either be sublimated to ethical ones or, at least, would be
balanced among competing interests.A doctor’ s ethical decision making is more difficult in
3. the United States than it is in the United Kingdom. The British National Health Service
provides universal health care to all citizens, but it makes explicit what medical procedures
will not be supported. More elaborate xray, MRI, and Cat Scans are not supported, for
example, under the justification that their cost would subtract from the care provided to the
remainder of the population. In other words,medical resources are rationed. Of course, the
middle class and wealthy can fly to countries suchas Belgium and receive any treatment
they can afford to pay for, so health care is really onlyrationed for the working class and the
poor.American doctors are pressured on both sides: by their patients to provide treatments
ofquestionable worth and by HMOs and hospital administrators to limit the use of
expensive testsand treatments. In the U. S. the cost-containment role is taken over by a
number of organizationssuch as HMOs that pressure hospitals and doctors to limit
expensive procedures. A doctor riskshis livelihood and practice if he or she continually
orders tests and procedures that arediscouraged by HMO accountants. Doctors and
hospitals are also financially rewarded if theyspend less than the amount set by the HMO.
Thus by means of operant conditioning, they aretaught to provide their patients less service
than might be appropriate. Some authors believe thatthis conditioning turns doctors into
double agents who slight their patients in favor of HMOs andother institutions.In this
connection, an Oklahoma study (Khalig, Broyles, & Robertson, 2003) found thatinsurance
status, prospective payment, and the unit of payments make a difference in the lengthof
hospital stays. Medicare-insured, Medicaid-insured, and the uninsured
experiencesignificantly shorter episodes of hospitalization than their commercially insured
counterparts.These shorter stays were found to contribute to physician-induced
(iatrogenic) injury. This studyand many others argue that medicine in the United States
needs to find a different method offinancing. Whatever happens, however, the chances are
that, because of the progress in treatingchronic diseases and American’ s high expectations,
the cost of health care will continue to riseno matter who pays for it.Another reason that
medical costs are high in this country is the American tort system.Premiums got so high in
West Virginia because of the thousands of law suits against doctors thatphysicians staged a
1-day strike to protest. Worse, so many physicians have moved out of thatstate that people
in some areas have to drive two or more hours to see a doctor. Two issues areimportant
here. The first is the many unnecessary lawsuits that people bring against doctors,lawsuits
that frequently cost insurance companies millions of dollars.On the other hand, doctors, like
the rest of us, make mistakes. For example, if a doctorsews up after an operation and leaves
a clamp inside the patient, what should he or she do?Ignore it and hope for the best? Wait
until the patient reacts badly and then reopen? Cover upthe incident? Confer with lawyers
to design a defense strategy? Consult with accountants to seeif his or her insurance
premiums will skyrocket? Tell the patient and relatives what happened,apologize, reopen,
and correct the mistake?Thurman (as cited in Card, 2004) says that the barriers to
admitting mistakes are:1. The provider’ s difficulty in confessing mistakes.2. The fear of
implicating other providers.3. The possibility of liability exposure. (p. 484)The first barrier
has psychological force but no ethical force. We all make mistakes, but ethical people admit
and correct them as quickly as possible. Honest admission of mistakes is cheaper than
cover-up because cover-up adds fraud to mere malpractice and angers the patient or
4. family, who might then sue the doctor or hospital. Doctors are discouraged from speculating
about the behaviors and intentions of other providers. Instead, they should relate only their
present observations of a patient and not assign guilt to anyone. Both the national and state
legislatures are currently struggling to find a solution to medical liability that is fair to both
doctors and to patients who have truly been harmed. Some states, like New York and
Pennsylvania, exempt “ mere” medical malpractice from punitive damages.
