Healthcare Management Ethics and Definitions

Resource Allocation in Healthcare/Ethics of Public Health and Health Promotion

• The topic focuses on resource allocation in healthcare and the ethical considerations in public health and health promotion.
• Learning outcomes include outlining the importance of resource allocation, explaining ethical issues and principles, outlining public health ethics, and explaining ethical issues related to public health.
• The outline for the lecture covers learning outcomes, introduction, main ethical principles relevant to resource allocation, different approaches to allocating resources in healthcare, why resource allocation is important for practice, ethical considerations for fair allocation, and how to use frameworks to allocate resources in practice.

Introduction: Ethical Issues and Principles in Resource Allocation

• There are never enough resources for everyone, and there are always health needs requiring consideration.
• Healthcare needs are categorized as basic, secondary, or tertiary, with some being more fundamental than others.
• Key areas to consider when allocating resources include money, time allocation to patients, and allocating beds/drugs.

Different Approaches to Resource Allocation in Healthcare

• Consequentialist and utility principle approach
• Deontological (duty-based) approach
• Cost-effectiveness, quality-adjusted life-years (QALYs), and disability-adjusted life-years (DALYs)
• Principle-based (Principlism)
• Fair process approach (accountability for reasonableness)

Cost-effectiveness, Quality-Adjusted Life-Years (QALYs), and Disability-Adjusted Life-Years (DALYs)

• Cost-effectiveness analysis (CEA) assesses the costs and benefits of different health interventions to determine their efficiency.
• QALYs and DALYs quantify the quality and length of life, respectively, considering the impact of interventions.

Principle-Based Approach (Principlism)

• Principlism is a method for addressing professional deontology by grounding it in core principles.

What is Hippocrates' Oath?

• "First, do no harm" or "Primum non nocere" is a fundamental principle in medicine.

Fair Process Approach (Accountability for Reasonableness)

• This approach focuses on the process of allocating resources fairly and emphasizes accountability and reasonableness.
• Norman Daniels's principles for a fair process include transparency/publicity, participation, effectiveness/relevance, and appeal.

Norman Daniels' Principles

• Transparency/publicity: Information about decision-making processes and criteria should be accessible to affected populations.
• Participation: Stakeholders should be involved in the processes of formulating objectives and adopting policies.
• Effectiveness/Relevance: Principles must be translated into practice in a manner relevant to population health needs.
• Appeal: A mechanism for stakeholders to petition policies already adopted should exist.

Why is Resource Allocation Important for Practice?

• Improper resource allocation leads to dissatisfaction among patients and medical staff.
• Ethical considerations are critical in determining the best allocation practices

Ethical Considerations for Fair Resource Allocation

• CEA (Effectiveness): Prioritize those conditions most likely to achieve a positive health outcome.

• Medical Need: Favor those most in need of intervention or most vulnerable in society.

• Utility: Aim for the lowest possible morbidity/mortality given available resources.

• Immediate Usefulness: Prioritize those with special skills that can best serve the common good immediately.

• General Social Value: Give preference to individuals who are considered valuable to society (past or future).

• Principle of Conservation: Prioritize those who use fewer resources proportionally.

• Responsibility for Dependents: Prioritize those with primary caregiving responsibilities.

• None if not all: Do not save one if all cannot be saved.

• Queue: Prioritize based on a first-come, first-served basis.

• Random Selection: Resource allocation based on chance, for example, through a lottery.

• Ability to Pay: Resource priority based on a patient's financial capacity to pay.

• Merit-based: Priority based on earned merit due to past actions.

How to Use Resource Allocation in Practice: Frameworks

• The American College of Healthcare Executives (ACHE) framework
• Hamilton Health Sciences (ISSUES) framework

Conclusion

• Healthcare resources are often insufficient.
• Prioritization is frequently necessary for fair resource allocation.
• Ethical considerations are paramount in the allocation decisions to meet professional commitments.

Ethics of Public Health and Health Promotion

• The concepts include health, illness, family health, community health, preventive medicine, the significance of public health ethics, ethical, legal, and policy issues, and a summarization and conclusion.

Introduction: Basic Concepts

• Health is a positive state of being, not just the absence of disease.
• This holistic perspective considers physical, mental, psychological, spiritual, and social wellbeing.

Components of Good Health

• Physical, mental, psychological, social, and spiritual wellbeing are all interconnected and essential for overall well-being.

The Concept of Illness

• Disease signifies a state of disequilibrium, while illness is a subjective experience.

The Concept of Family Health

• A healthy family promotes health in its members and acts as an economic unit providing primary health care.

The Concept of Community Health

• Community health involves collective efforts to promote, protect, and preserve health within a community (both private and public).
• Community health needs community input, while public health emphasizes governance.

Community Diagnosis

• Identifying and describing health issues in a community is central to initiating public health interventions.

Community Health

• Social and moral factors contribute to the causes of poor community health.
• Community health can be improved by promoting healthy individuals and fostering cooperation.

The Concept of Health Promotion

• Community-level spiritual promotion involves adhering to good practices and avoiding harm.
• Individual-level physical health promotion involves immunization, nutrition, hygiene, and disinfection.
• Community-level health promotion encompasses environmental sanitation.

What Does Health Promotion Involve?

• Proactive measures such as exercise, good nutrition, adequate rest, and calmness (mental and spiritual) improve health status.

Why are Public Health Ethics Important?

• Public health addresses disease and illness at a community level, contrasting with clinical medicine's focus on the individual patient.

Ethical Issues Related to Public Health Interventions

• Ethics considerations in public health initiatives center around balancing benefits with potential risks.

Ethical, Legal, and Policy Issues

• The prioritization of disease prevention over treatment presents a significant ethical, political, and economic controversy.

Levels of Prevention

• Primary prevention, like immunization, aims to prevent the occurrence of disease.
• Early detection and treatment may result in complete cure or reduce disease complications.
• Preventive interventions are more economical than curative care.

Concepts of Equality and Equity in Healthcare

• Equality implies equal access to advanced care, while equity acknowledges varying needs and aims to address them accordingly via fair distribution of resources.

Ethical Issues in Priority Setting in Health Resource Allocation

• Reaching a consensus on criteria for prioritization is a fundamental challenge in resource allocation.

Ethical Issues in Epidemiological Research

• Informed consent and data confidentiality are necessary elements in epidemiological research.
• Misunderstandings surrounding risk reported by the mass media can pose an ethical problem.

Ethics of Disease Screening

• Demonstrated efficacy of the screening procedure is required.
• Informed consent from participants is essential.
• Maintaining confidentiality of personal information is imperative during the screening process.
• Ethical question arises in screening for diseases that are currently incurable or untreatable.

Ethics of Contagious Disease Control

• In epidemics, limitations on citizens' rights are often warranted in the public interest.
• Coercive measures such as quarantine, compulsory treatment, and immunization, can be used.
• Contact tracing and notification regarding communicable diseases may require breaching confidentiality; nevertheless, this is justifiable in the public interest.

Smoking and Drug Addiction Control

• Addiction to nicotine, alcohol, and psychoactive drugs poses a significant social problem.
• Restrictions on individual autonomy are sometimes necessary to address this problem in the public's best interest.

Ethical Issues in Vaccination

• Vaccination creates herd immunity, preventing the spread of endemic and epidemic diseases.
• Vaccination programs are typically mandatory to ensure herd immunity in areas where vaccination is needed.

Ethical Issues in Disasters

• Treatment priorities during natural or man-made disasters must be ethically determined.
• Weaker members of society, the seriously injured, and immediate suffering must take high priority in triage.

Conclusion (Summary)

• Public health ethics are as varied and complex as in clinical medicine.
• Public health ethics affect the general public and not just individual patients.

Case Studies (Examples)

• Case 1 (Preventive vs. Curative Medicine): Illustrates the dilemma of choosing between prevention and treatment in resource allocation decisions.
• Case 2 (Controversy about Childhood Immunization): Highlighting the ethical challenges of balancing personal interests with public health interests.
• Case 3 (Autonomy vs Benefit): Illustrates the frustration experienced by public health officials when effective preventive measures are not carried out, stressing that coercion is not ethical in this situation.
• Case 4 (Disclosure to Protect Others vs. Patient's Right to Privacy): Underscores the ethical considerations surrounding breaches of confidentiality when public health interests are involved.
• Case 5 (Public Interest vs. Individual Autonomy): Illustrates the tension between the public good and individual autonomy, especially in mandatory vaccination programs.
• Case 6 (Public vs Individual interests and autonomy): Illustrates mass vaccination in a public health emergency as an example of overriding personal interests in the interest of public health.

References

• Module 12 and 13 from a Professionalism and Ethics Handbook for Residents (PEHR) by Hussein GM, Alkabba AF, Kasule OH is referred to.