Why is there a need for resource allocation?
Healthcare resources are finite. Simply digging deeper is not a long-term solution. For some interventions, there is an absolute scarcity of resources e.g., organ transplants.
What are the arguments for using age in resource allocation?
- YES: older person has already enjoyed more life; life expectancy shorter; older individual has less time to give back to society.
- NO: allocation based on age would be arbitrary (e.g., 19y/o before 20y/o); an older individual will have contributed to society for longer so would be more deserving of having life saved; two individuals of different age would both value their lives equally.
BUT ‘Fair Innings argument’: people generally value their lives equally irrespective of age, but at a certain age e.g., 70 y/o, one can be said to have had their fair share of life. Any addition life over this ‘fair innings’ is a bonus and does not warrant public resources.
- BUT, who decided what would count as fair innings? A 30 year old with cancer and one month to live would receive treatment rather than the 71 year old with appendicitis. Why is 70 years a fair innings, but not 69? Does this not devalue elderly life?
- Instead, could we apply this argument to only some features of health, not all e.g., organ transplant and expensive treatments?
What are the arguments for using social worth in resource allocation?
• Who would decide this? • Biased against those with disability. • Social worth is rewarded in other ways e.g., income and prestige, but not through considering some lives more worthy of saving than others.
What are the arguments for using dependents as a factor in resource allocation?
• If a single mother of 3 dies, then the lives of her children will be blighted, and society will have to pick up the costs of caring for her children. • BUT, those without dependents will have loved ones too whose lives will be blighted by their death. Equally, would a single mother of three have more priority over a single mother of one? Those of us without dependents still value our lives the same.
What are the arguments for using personal responsibility as a factor in resource allocation?
- To what extent are people responsible for the diseases they acquire?
- But what about factors beyond our control e.g., upbringing, education, social background, genes could make someone fat. Does this mean it’s their fault?
- If we uphold this, what happens to rescuing mountaineers and treating sports injuries?
How does justice override the above arguments of resource allocation? But?
The right to life is arguably a fundamental right. If we believe everyone is equal, then everyone has an equal right to life and therefore an equal right to be saved. Choosing between age, social worth and more would therefore be an injustice. BUT, is there a right to healthcare?
What are the arguments for using disease in resource allocation?
Rather than choosing between people, should we instead choose between diseases? We could therefore still argue that everyone has a right to healthcare, but that certain physical problems do not fall within that right e.g., cosmetic surgery and fertility treatment.
How do we choose between diseases in resource allocation? (x3)
QALY, evidence-based medicine or public opinion.
How does QALY work?
- Quality-adjusted life years:
- 1 QALY = 1 year of healthy life
- <1 QALY = 1 year of unhealthy life
- 0 QALY = death
- If cost of intervention is known, you can calculate cost per QALY
- Preference scores give an adjustment between -1 and +1 of the QALY based on the predicted quality of life associated with a condition, using questionnaires focusing on function: motility, personal self-care and communication. Negative QALY are therefore possible.
What are the arguments for and against using QALY in resource allocation?
- Benefits: give a reproducible measure of benefit:cost
- Problems: biased against people of disability, ageist, doesn’t distinguish between saving a life and improving a life, preference scoring is subjective, and equates QoL with value of life.
What are the arguments for evidence-based medicine in resource allocation between diseases?
• To determine which interventions should be provided and chance of benefit • BUT, this does not help when there is little research about an intervention, there is potential for industry bias, interventions with a lot of research are likely to be prioritised.
What are the arguments for public opinion in resource allocation between diseases? Example?
- If we follow public opinion, and resources are insufficient, it is down to the public to either revise its list of interventions as healthcare priorities, or pay more tax
- BUT, what about vulnerable groups who lack a strong voice, or those with conditions that evoke less public sympathy e.g., HIV.
- Case of Oregon State: general public asked to rank a list of over 700 medical conditions in terms of priority for universal state provision. They voted highly for treatment for thumb sucking, and poorly for cystic fibrosis and appendicectomy. Therefore, public knowledge may make this more damaging to health.
How does personal choice provide a solution to resource allocation? Disadvantage of this argument?
We all have different health priorities. Why not give individuals the money to invest in a personal health insurance plan of their choice? BUT, our health priorities and perception of illness change with time, and would the inevitable differences in healthcare access be socially acceptable?
What are the arguments for maximising lives saved in resource allocation?
Imagine you are responsible for the health budget. You have been told:
- Primary angioplasty is the first line treatment for MI and costs between £15K-£30K
- The same money could be used in primary prevention to give statins to 200 people and prevent 2 future heart attacks.
Primary prevention saves more lives; therefore, should more resources be directed towards it? However, there are problems with this argument:
- Flooded floor scenario: If the floor is flooded, don’t mop the floor, fix the tap!
- Problem with the flooded floor scenario: (1) assumes that only one tap is leaking, (2) that you can fix the tap, (3) that fixing the tap won’t cause new problems.
- You can apply this argument to treating obesity: 60% of population is obese or overweight. It is associated with CVD, diabetes, arthritis and cancers
- Flooded floor scenario: it is an appropriate and necessary use of resources to tackle obesity through prevention and treatment
- Problem with the flooded floor scenario: (1) it is difficult to separate the contribution of obesity to premature death from other confounders which associate with obesity such as poverty and education level. (2) Primary prevention interventions for obesity have been unsuccessful. (3) Screening for obesity risks medicalising otherwise healthy individuals. Screening for obesity also takes away resources from treating other diseases.
What is the problem with resource allocation? Summary?
Approaches to resource allocation have been proposed, but these can be problematic as they can be interpreted as implying that some lives (or some diseases) are more valuable than others. Whatever the approach, it must be transparent and accountable if it is perceived to be as fair.
