Resource Allocation in Healthcare and Ethics of Public Health PDF

RESOURCE ALLOCATION IN HEALTHCARE/ ETHICS OF PUBLIC HEALTH AND HEALTH PROMOTION DR SHANTHI VANKA Learning Outcomes Outline the importance of resource allocation in clinical practice Explain the various ethical issues and principles in resource allocation Outline the concepts of public heal...

RESOURCE ALLOCATION IN HEALTHCARE/ ETHICS OF PUBLIC HEALTH AND HEALTH PROMOTION DR SHANTHI VANKA Learning Outcomes Outline the importance of resource allocation in clinical practice Explain the various ethical issues and principles in resource allocation Outline the concepts of public health ethics Explain the ethical issues related to public health RESOURCE ALLOCATION IN HEALTHCARE Outline Lecture Learning Outcomes Introduction Main ethical principles that are relevant to this issue Different approaches to allocation of resources in health care Why is resource allocation important for our practice Ethical considerations to achieve a fair allocation of resources How to use resource allocation in your practice - Frameworks Introduction: What are the ethical issues and principles in resource allocation? There are never enough resources for everyone There are always health needs. Types of Health care needs Some are considered Some are basic secondary and tertiary Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 147 What are most important points to be considered in resource allocation? Money Time allocation to patients Time allocation of beds or drugs Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 147  Different approaches to allocation of resources in health care APPROACHES Cost-effectiveness, Consequentialist quality-adjusted life- Fair process and utility Deontological Principle-based approach (duty-based) years (QALYs) and approach principle (Accountability for approach disability-adjusted (Principlism) approach life-years (DALYs) reasonableness) Transparency/publicity Participation Effectiveness/Relevance Appeal Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 148 Cost-effectiveness, quality-adjusted life-years (QALYs) and disability-adjusted life-years (DALYs) A cost-effectiveness analysis (CEA) compares the respective costs and benefits of alternative health intervention measures to determine their relative efficiency in the production of health. Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 148 Principle-based approach (Principlism) Principlism is one way of approaching professional deontology. Put simply, it is based on stating one or more principles from which stem duties. Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 148 What is Hippocrates’ oath? “First, do no harm” or “Primum non nocere” Fair process approach (Accountability for reasonableness) This approach is focused more on the process of allocating resources For a “fair process” of resource allocation, Norman Daniels suggested a set of principles that should be followed in decision making: Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 149 Norman Daniels principles followed in decision making Transparency/publicity: Information about the processes and bases of decisions should be made available to the affected population. Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 149 Norman Daniels principles followed in decision making Participation: The stakeholders should be involved in the processes of formulating the objectives and adopting the policies. Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 149 Norman Daniels principles followed in decision making Effectiveness/Relevance: States that there must be ways to translate the other principles into practice relevant to meeting population health needs fairly. Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 149 Norman Daniels principles followed in decision making Appeal: Stakeholders should have a way to put a petition for policies after they have been adopted. Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 149 Why is resource allocation important for our practice If resource allocation is not done properly it may lead to a level of dissatisfaction among patients and medical staff. The best way to do the resource allocation is to decide based on an ethical basis. Ethical considerations to achieve a fair allocation of resources CEA: (Effectiveness) - priority given to those most likely to achieve a good outcome, i.e., medical success Medical Need - priority given to those most in need of medical intervention, or those considered most helpless or generally neediest in society (vulnerable groups) Utility - achieving the least morbidity/mortality possible, given the resources available (maximizing good health/survival with the available resources) Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 148 Ethical considerations to achieve a fair allocation of resources Immediate Usefulness - priority given to those with special skills that could be used to serve the common good in the immediate circumstance General Social Value - priority given to those who are considered by society to have the greatest social worth (past or future) Principle of Conservation - priority given to those who use proportionally less resources Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 150  Ethical considerations to achieve a fair allocation of resources Responsibility for Dependents - priority given to those who have primary responsibilities to dependents (parents, nursing home attendants, etc.) None if not all - no one should be saved if all cannot be saved Queue - priority given on a first-come, first-served basis Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 150  Ethical considerations to achieve a fair allocation of resources Random Selection - allocation determined by chance (a lottery, for example) Ability to Pay - priority given to those who can pay for the resources Merit based - priority given to those who have earned it due to past actions Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 150 How to use resource allocation in your practice: Frameworks 1. The American College of Healthcare Executives (ACHE) framework 2. The Hamilton Health Sciences (ISSUES) framework Reference: Module 12: Professionalism and Ethics Handbook for residents Pages 150 Conclusion There are rarely enough health care resources for everyone. At some point, there will be a need to prioritize the beneficiaries of the service that you provide in a fair way that fulfills your professional commitments. ETHICS OF PUBLIC HEALTH AND HEALTH PROMOTION Outline Lecture Learning Outcomes Introduction: Basic Concepts The Concept of Health The Concept of Illness The Concept of Family Health The Concept of Community Health The Concept of Preventive Medicine Why are public health ethics important? Ethical, legal and policy issues Conclusion and summary  Introduction: Basic Concepts The Concept of Health: Health is a positive state of being, not just the absence of disease. Individuals who are disease-free may not be healthy. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:159 Components of Good Health Psychological health Physical Mental Health health Spiritual Good Social health health Health These components have to be seen in a holistic way because Islam looks at health and all other aspects of life from a comprehensive and integrative perspective. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:159  The Concept of Illness In general, disease is a state of dis-equilibrium. Disease A pathological manifestation Illness A subjective feeling Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:160  The Concept of Family Health A healthy family promotes the health of all its members. It is an economic unit and the main source of primary health care. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:160  The Concept of Family Health The causes of family dysfunction are multiple: economic pressures, a hedonistic lifestyle, and a decline of moral and religious values in society. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:160 The Concept of Community Health Community health covers private and public efforts of individuals, groups, and organizations to promote, protect, and preserve the health of those in the community. Organization Community development Participation and diagnosis What does community health involve?? Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:160 Community health and Public health Community health is community-driven. Public health is government-driven. Government Community Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:160 Community diagnosis Community diagnosis consists of identifying and describing health problems in a group of people with a view to initiating public health interventions. Identifying and describing health problems in a group of people Community Diagnosis A view to initiating public health interventions Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:160 Community health Causes of poor community health: Social and Moral factors Community health can be improved by having healthy individuals in the community, and establishing mutual cooperation and mutual complementation Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:160 The Concept of Health Promotion Spiritual promotion at the community level involves enjoining the good and forbidding the evil. Most diseases can be prevented using spiritual approaches. These involve aqiidat, ibadat, avoiding haram and promoting halaal. Physical health promotion at the individual level includes immunization, good nutrition, personal hygiene, and disinfection. Physical promotion at the community level involves environmental sanitation. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:161 What does Health promotion involve? Proactive measures that make health better, such as exercise, good nutrition, adequate rest, mental calmness, tranquility of family life and spiritual calmness. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:161 Why are public health ethics important? Public health involves measures disease and illness at a community level, in contrast to clinical medicine, which deals with disease and illness at an individual level. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:161 Ethical issues related to public health interventions Ethics requires maximizing benefits and minimizing risks. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:161 ETHICAL, LEGAL AND POLICY ISSUES Disease prevention versus disease treatment A serious ethical, political, and economic debate surrounds the prioritization of resource allocation to preventive as opposed to curative care. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:162 Levels of prevention Primary prevention of disease by immunization will stop its occurrence altogether. Early detection and treatment of disease may result in complete cure or less complications. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:162 Benefit of preventive interventions Preventive interventions are much cheaper than curative ones. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:162  Concepts of equality and equity in health care The ideal of equality would be to provide the most advanced care available to every citizen. Health care resources are limited, and some form of rationing must be put in place. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:162  Concepts of equality and equity in health care Since public health resources are limited, citizens have to pay for some services. Those who are richer are able to enjoy a higher level of health care than the poor; that perfect equality in health care is not possible. The only feasible alternative is to aim at equity, which is providing for each person the appropriate health care for his/her time, place, and social circumstances. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:162  Ethical issues in priority setting in health resource allocation The practical problem is to reach agreement on the criteria of prioritization. ISSUES RELATING TO PRIORITIZING ALLOCATION: 1. Preventive vs. curative care 2. Equality vs. equity. 3. Rural vs. urban prioritization 4. Primary vs. tertiary care 5. Most vulnerable (children and women) versus the rest of society. 6. Different disease or illness conditions (acute conditions, chronic and endemic widespread conditions). No rules on prioritization can be made to fit all situations. The best approach is to deal with each situation on its own merits, with the overall objective of maximizing benefit. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:163 Ethical issues in epidemiological research Like any other forms of research, epidemiological research requires informed consent if personal data with identifiers are collected. The data must be kept confidential and should be reported only in aggregate. Informed consent is required to report any individual’s data. Misunderstandings occur when risk is reported by the mass media. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:163  Ethics of disease screening The efficacy of the screening procedure must have been demonstrated by a proper trial. Informed consent must be obtained from participants Confidentiality must be maintained for all personal and other information collected during the screening. Whether screening should be undertaken for diseases that are untreatable also poses an ethical question. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:163  Ethics of contagious disease control In an epidemic, the civil rights of citizens are restricted in the public interest. Coercive measures are taken without seeking informed consent: quarantine, compulsory treatment, and compulsory immunization. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:164  Ethics of contagious disease control When a communicable disease is diagnosed, the usual medical confidentiality is broken. Contact tracing and notification of authorities involve breaches of confidentiality that are justifiable in the public interest. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:164 Smoking and drug addiction control Addiction to nicotine, alcohol, and psychoactive drugs is a major social problem that underlies crime and family breakdown and highlights the issue of personal autonomy versus public interest. It is therefore in the public interest that the autonomy and other civil rights of citizens be restricted. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:164  Ethical issues in vaccination Vaccination, helps create herd immunity that will prevent spread of endemic and epidemic communicable diseases. It is therefore compulsory, in Saudi Arabia, that all children get scheduled immunizations at the right times. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:164  Ethical issues in disasters In a man-made or natural disaster situation, decisions have to be made about treatment priorities: 1. To the weakest members of society: children with their mothers, and the elderly 2. To the more seriously injured 3. Short-term against the long-term effects of a disaster. 4. To interventions aim at relieving immediate suffering 5. To focus on the long-term implications Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:164 Conclusion Ethical issues are as many and varied in public health as they are in clinical medicine. These issues have to be taken seriously because they affect the general public, not just individual patients. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:169 References Module 12 and 13- Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015 THANK YOU TUTORIAL Learning Outcome Demonstrate awareness of legal and ethical aspects of issues related to public health  Case 1: Preventive versus curative medicine Scenario: A heated argument in the city council occurred between the Public Health Officer, who wanted to get funding for a community heart disease education program that would cost SR 50,000 a year, and members of the council, who wanted to allocate a higher budget to set up a coronary care unit costing SR 5 million. Eventually, the decision was made to set up the coronary care unit because of the votes of a majority of council members who were elderly, some of who had heart disease. Hint: This case illustrates the dilemma of choosing between prevention and cure when allocating health resources. It also demonstrates that curative medicine usually wins out because of the preferences of powerful members of society. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:158  Case 2: Controversy about childhood immunization Scenario: In a wealthy neighborhood of the city, professionals (including doctors) refused to take their children for measles vaccination, arguing that the side effects of the vaccine-though low overall-were much higher than the risk of measles, which had not been diagnosed in their community for the past 10 years. They also argued that their children went to neighborhood schools, and did not mix with children from areas where measles was endemic. Hint: This case illustrates the unethical attitude of putting personal interests before public interests. If everybody thinks only of his own interests, the whole community will suffer. In this case, the result may be a significant reduction of herd immunity eventually leading to epidemic spread of the infection. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:158  Case 3: Autonomy versus benefit Scenario: Noticing a 3-fold increase in diagnosis of late stage colon cancer that was fatal within a year, the city council passed a resolution requiring all men and women above 40 to undergo colonoscopic screening once every 5 years, with the warning that those who refused screening would not be treated for free if they got cancer. Hint: This case illustrates the frustration of public health officials, who cannot implement effective evidence-based preventive measures because of refusal by the population. Coercion is not ethical in this case. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:158  Case 4: Disclosure to protect others versus patients’ right to privacy and confidentiality Scenario: A doctor examining a citizen returning from overseas found him positive for HIV. The doctor immediately looked up the man’s home phone number in the telephone directory and informed the wife to take measures to avoid infection. The wife went to court and filed for divorce. Hint: The doctor had a duty to protect the wife and the family and this duty involves breach of confidentiality. The doctor’s mistake was the method used, which ended up causing an unnecessary divorce. He was supposed to notify authorities with experience in contact tracing for infectious disease so that they could handle the matter professionally. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:159  Case 5: Public interest versus individual autonomy Scenario: A university research center developed a vaccine that, if given to teenagers, would prevent addiction to cigarettes by generating antibodies that would prevent the nicotine from crossing the blood- brain barrier. Realizing the potential benefit, the Ministry of Health passed a law making vaccination compulsory for all boys, but not for girls. Hint: Although vaccination benefits the public by stopping addiction, it violates individual autonomy, especially of those who would not be exposed to drugs. The antibodies constitute a permanent change in the body that could have other, as yet unknown, effects. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:159  Case 6: Public versus individual interests and autonomy The Ministry of Health ordered mass vaccination in a new flu virus epidemic that had just spread from a neighboring country. Citizens objected to vaccination without their consent. Hint: Public interest takes precedence over private interest and will override individual autonomy. In this case, compulsory vaccination is justified if there is strong scientific evidence for its effectiveness. Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015, module 13, p:158 References Module 12 and 13- Hussein GM, Alkabba AF, Kasule OH. Professionalism and Ethics Handbook for Residents (PEHR): A Practical Guide. Ware J, Kattan T (eds). 1st Edition. Riyadh, Saudi Arabia: Saudi Commission for Health Specialties, 2015 THANK YOU