Rationing Health Dictionary

Within most cultures, care of the sick is seen as entailing special duties, codi?ed as a set of moral standards governing professional practice. Although these duties have been stated and interpreted in di?ering ways, a common factor is the awareness of an imbalance of power between doctor and patient and an acknowledgement of the vulnerability of the sick person. A function of medical ethics is to counteract this inevitable power imbalance by encouraging doctors to act in the best interests of their patients, refrain from taking advantage of those in their care, and use their skills in a manner which preserves the honour of their profession. It has always been accepted, however, that doctors cannot use their knowledge indiscriminately to ful?l patients’ wishes. The deliberate ending of life, for example, even at a patient’s request, has usually been seen as alien to the shared values inherent in medical ethics. It is, however, symptomatic of changing concepts of ethics and of the growing power of patient choice that legal challenges have been mounted in several countries to the prohibition of EUTHANASIA. Thus ethics can be seen as regulating individual doctor-patient relationships, integrating doctors within a moral community of their professional peers and re?ecting societal demands for change.

Medical ethics are embedded in cultural values which evolve. Acceptance of abortion within well-de?ned legal parameters in some jurisdictions is an example of how society in?uences the way in which perceptions about ethical obligations change. Because they are often linked to the moral views predominating in society, medical ethics cannot be seen as embodying uniform standards independent of cultural context. Some countries which permit capital punishment or female genital mutilation (FGM – see CIRCUMCISION), for example, expect doctors to carry out such procedures. Some doctors would argue that their ethical obligation to minimise pain and suffering obliges them to comply, whereas others would deem their ethical obligations to be the complete opposite. The medical community attempts to address such variations by establish-ing globally applicable ethical principles through debate within bodies such as the World Medical Association (WMA) or World Psychiatric Association (WPA). Norm-setting bodies increasingly re?ect accepted concepts of human rights and patient rights within professional ethical codes.

Practical changes within society may affect the perceived balance of power within the doctor-patient relationship, and therefore have an impact on ethics. In developed societies, for example, patients are increasingly well informed about treatment options: media such as the Internet provide them with access to specialised knowledge. Social measures such as a well-established complaints system, procedures for legal redress, and guarantees of rights such as those set out in the NHS’s Patient’s Charter appear to reduce the perceived imbalance in the relationship. Law as well as ethics emphasises the importance of informed patient consent and the often legally binding nature of informed patient refusal of treatment. Ethics re?ect the changing relationship by emphasising skills such as e?ective communication and generation of mutual trust within a doctor-patient partnership.

A widely known modern code is the WMA’s International Code of Medical Ethics which seeks to provide a modern restatement of the Hippocratic principles.

Traditionally, ethical codes have sought to establish absolutist positions. The WMA code, for example, imposes an apparently absolute duty of con?dentiality which extends beyond the patient’s death. Increasingly, however, ethics are perceived as a tool for making morally appropriate decisions in a sphere where there is rarely one ‘right’ answer. Many factors – such as current emphasis on autonomy and the individual values of patients; awareness of social and cultural diversity; and the phenomenal advance of new technology which has blurred some moral distinctions about what constitutes a ‘person’ – have contributed to the perception that ethical dilemmas have to be resolved on a case-by-case basis.

An approach adopted by American ethicists has been moral analysis of cases using four fundamental principles: autonomy, bene?cence, non-male?cence and justice. The ‘four principles’ provide a useful framework within which ethical dilemmas can be teased out, but they are criticised for their apparent simplicity in the face of complex problems and for the fact that the moral imperatives implicit in each principle often con?ict with some or all of the other three. As with any other approach to problem-solving, the ‘four principles’ require interpretation. Enduring ethical precepts such as the obligation to bene?t patients and avoid harm (bene?cence and non-male?cence) may be differently interpreted in cases where prolongation of life is contrary to a patient’s wishes or where sentience has been irrevocably lost. In such cases, treatment may be seen as constituting a ‘harm’ rather than a ‘bene?t’.

The importance accorded to ethics in daily practice has undergone considerable development in the latter half of the 20th century. From being seen mainly as a set of values passed on from experienced practitioners to their students at the bedside, medical ethics have increasingly become the domain of lawyers, academic philosophers and professional ethicists, although the role of experienced practitioners is still considered central. In the UK, law and medical ethics increasingly interact. Judges resolve cases on the basis of established medical ethical guidance, and new ethical guidance draws in turn on common-law judgements in individual cases. The rapid increase in specialised journals, conferences and postgraduate courses focused on ethics is testimony to the ever-increasing emphasis accorded to this area of study. Multidisciplinary practice has stimulated the growth of the new discipline of ‘health-care ethics’ which seeks to provide uniformity across long-established professional boundaries. The trend is to set common standards for a range of health professionals and others who may have a duty of care, such as hospital chaplains and ancillary workers. Since a primary function of ethics is to ?nd reasonable answers in situations where di?erent interests or priorities con?ict, managers and health-care purchasers are increasingly seen as potential partners in the e?ort to establish a common approach. Widely accepted ethical values are increasingly applied to the previously unacknowledged dilemmas of rationing scarce resources.

In modern debate about ethics, two important trends can be identi?ed. As a result of the increasingly high pro?le accorded to applied ethics, there is a trend for professions not previously subject to widely agreed standards of behaviour to adopt codes of ethical practice. Business ethics or the ethics of management are comparatively new. At the same time, there is some debate about whether professionals, such as doctors, traditionally subject to special ethical duties, should be seen as simply doing a job for payment like any other worker. As some doctors perceive their power and prestige eroded by health-care managers deciding on how and when to ration care and pressure for patients to exercise autonomy about treatment decisions, it is sometimes argued that realistic limits must be set on medical obligations. A logical implication of patient choice and rejection of medical paternalism would appear to be a concomitant reduction in the freedom of doctors to carry out their own ethical obligations. The concept of conscientious objection, incorporated to some extent in law (e.g. in relation to abortion) ensures that doctors are not obliged to act contrary to their own personal or professional values.... ethics

As the needs and demands of patients, and the costs of health care of populations, have risen sharply in recent years, governments and health-care providers – whether tax-funded, insurance-based, employer-provided or a mix of these – have had increasingly to face the dilemma of what services a country or a community can a?ord to provide. As a result, various techniques for deciding priorities of care and treatment are evolving. In the United Kingdom, priorities were for many years based on the decisions of individual clinicians who had wide freedom to prescribe the most appropriate care. Increasingly, this clinical freedom is being circumscribed by managerial, community and political decisions driven in part by the availability of resources and by what people want. Rationing services, however, is not popular and as yet no broadly agreed consensus has emerged, either in western Europe or in North America, as to how priorities can be decided that have broad community support and which can be a?orded. (See CLINICAL GOVERNANCE; EVIDENCE-BASED MEDICINE.)... health-care priorities

Access to medical information via the Internet is widespread in some populations, often serving more patients than doctors. In addition to the huge variety of information available, patients can share experiences via electronic discussion groups, or obtain e-mail advice on a fee-for-service basis. Some professional organisations and journals provide free access to information, and the Internet can be a useful resource for medical practitioners and researchers. Concerns have arisen about the growth in electronic medical information: some believe that patients who have unlimited access to information via the Internet will be less likely to tolerate health-care rationing or will demand treatments that may be inappropriate in their individual circumstances. Other criticisms relate to the quality and accuracy of the information provided, potential breaches of patient CONFIDENTIALITY, and the risk of increased accusations of medical negligence (see also ETHICS).... internet

an analytical process for weighing up the possible losses (costs) and gains (benefits) of an action or policy, often in monetary or numerical form, and usually as a means of deciding between alternatives. In medicine, it is particularly associated with the setting of priorities in allocating limited health-care resources. Analysis may result in a cost–benefit ratio. Compare risk–benefit analysis. See also consequentialism; quality of life; rationing.... cost–benefit analysis

an ironic ‘law’ stating that where good health care is most needed, it is usually least available. It was first stated by the Welsh GP Tudor Hart to underline the great difficulty in bringing areas of health-care poverty up to acceptable levels. See health inequalities; justice; need; rationing.... inverse care law

n. the moral requirement to treat people fairly and impartially and with a proper regard for their entitlements and deserts – although the ways in which ethicists and philosophers define fairness, entitlements, and deserts varies considerably. Justice is common to many theories of ethics and is one of the *four principles of medical ethics. Issues of justice are mainly, but not exclusively, concerned with the fair allocation of medical resources when these are limited, and can be encapsulated in theories of distributive justice (see desert; equality; need; rationing).... justice