L3 Inequalities and Ethics PDF

Inequalities and ethics – delivery of healthcare services Dr Ying-Qi Liaw Teaching Fellow (Values, Law & Ethics) [email protected]  Session outline What is Inequalities in Principles of Application to ‘formal healthcare setting distributive healthcare principle o...

Inequalities and ethics – delivery of healthcare services Dr Ying-Qi Liaw Teaching Fellow (Values, Law & Ethics) [email protected]  Session outline What is Inequalities in Principles of Application to ‘formal healthcare setting distributive healthcare principle of such as organ justice setting justice’? transplantation Learning outcomes Demonstrate an understanding of the formal principle of justice, and explain what makes differences relevant or irrelevant. Describe some of the inequalities that exist within the realm of transplantation and consider whether these are justifiable. Demonstrate understanding of some principles of distributive justice, and begin to apply these to the context of organ allocation. Who should have access? How do we allocate limited goods fairly? Examples 3 children fighting over a bag of chocolates 4 participants competing for a final spot for basketball team  Some key terms  Formal equality  Normative relevance – what is the morally relevant criteria?  Formal principle of justice – equity Formal equality Treat like cases alike ‘When two persons have equal status in at least one normatively relevant respect, they must be treated equally with regard to this respect’ The key question here: what is the relevant criteria for you to treat like cases alike? What’s (morally) relevant as criteria? The normative relevance aspect 3 children fighting over a bag of chocolates Child 1 picked up the chocolates first. Child 2’s name is Jordan. Child 3 owns the chocolates. What’s (morally) relevant as criteria? The normative relevance aspect 4 participants competing for a final spot for basketball team P1 showed up earliest. P2’s name is Jordan. P3 is the youngest. P4 showed the best skills. Formal principle of justice Broader principle that goes further – allows room for ‘equity’ Equals should be treated equally and unequals unequally in proportion to their relevant inequalities. This asks further question whether proportional treatment is necessary based on relevant differences. Application to healthcare delivery How do we allocate limited healthcare services fairly? The principle of distributive justice The more specific principles: Different (justifiable) ways in terms of allocation decisions – what/how to prioritise: 1. Strict egalitarianism 2. Utilitarianism 3. Prioritarianism 4. Sufficientarianism 5. Desert-based principle ‘Give everyone the same share’ Strict egalitarianism – it is intrinsically valuable that people have equal access to the same level of goods or services. Main focus – equality (rather than utility) Is this the most effective or efficient way of using resources? What is it to treat equally? Organ transplantation Three people in need of a kidney transplant One kidney available Assuming that there are no relevant differences in patients. To treat them equally, should we give nobody a transplant? Can/should we do something else? So perhaps we do need to treat people differently In what way patients can be different? Waiting time? Physiological difference? Age? Co-related diseases/medical/health conditions? How should we choose one out of three dying individuals to have the only one available live saving treatment? Some examples of answers – are they ethically reasonable? We could give it to the youngest because they would live longer We could give it to the one fittest as they are more likely to survive We could give it to the sickest because they need it the most We could give it to the kindest because kind people deserve to be treated nicely We shouldn’t give it to the one we liked best We shouldn’t draw lots as the one who needed it most or the youngest or the kindest might not get it The other principle of distributive justice ‘Give it to those who will benefit most’ Utilitarianism – maximises utility/ welfare Utilitarianism focuses on maximising the number of lives saved (meaning prioritising those most likely to survive / benefit) Why this could (but not necessarily) mean prioritising the younger or the fitter/heathier? ‘Give it to those who need the most’ Prioritisation – a good outcome would be one that can benefit the worse-off individuals Worse-off – one with greater needs But who is in greater need? Longer waiting time? Medical urgency? ‘Give it to those who are the most deserving’ Desert-based principle – merit-based People deserve certain resources in light of their actions. What could be the basis for this? - Contribution? Social worth? - Character? - Compensation? Criticism? ‘Make sure everyone has enough’ Sufficientarianism - to ensure that everyone can get enough of what we need ‘If everyone had enough it would be of no moral consequence whether some had more than others’ What is a sufficiency threshold? What do we do when the threshold is met? The actual allocation policy The allocation criteria – examples of what count as the ‘relevant’ criteria Kidney Transplantation: Deceased Donor Organ Allocation The compatibility of their blood group with the donor The similarity of their tissue type with the donor The similarity of their age with the donor How long they have been on the transplant waiting list or on dialysis How far apart their transplant hospital is from the donor’s hospital Policy dated: 09/12/2024 How difficult it would be for them to get another organ The actual allocation policy Kidney allocation policies try to balance various considerations, including: Waiting time Urgency & saving lives Utility/ transplant outcomes You may see how these relate to the principles just discussed; Prioritisation might cause further inequality News And further inequality Directed altruistic living donation – advertising on social media? How might this add further inequality in the organ transplantation system? Broader inequality Vulnerability Coercion Exploitation Harm The harsh truth When demand exceeds supply, the imposition of (prioritisation) criteria inevitably means that some are left without. Is there anything we can do to ensure fairness? Procedural fairness / procedural justice Further reading (optional) Moorlock G, Draper H. Empathy, social media, and directed altruistic living organ donation. Bioethics. 2018;32:289–297. https://doi.org/10.1111/bioe.12438 Medical ethics and law: a curriculum for the 21st century by Herring, Jonathan; Wilkinson, Dominic; Savulescu, Julian; 2020, Third edition. Chapter 15 (available as e-textbook from University library website) How does the offering system work? - Organ transplantation - NHS Blo od and Transplant : This website summarises how kidneys from deceased donors are offered to patients. Policies and guidance - ODT Clinical - NHS Blood and Transplant: This website offers a range of policy documents on how different organs are allocated.