Explain the financial, social worth, and medical factors that influence how organ transplants are awarded.2. Contrast the American and British ways of rationing health care.a. What are the benefits and weaknesses of each?b. In which system is it ethically easier for a physician to say “no” to a request for expensive treatment? Why?c. Which system do you think is the most ethical and why?There was a time not long ago when doctors could offer only limited help, but theydispensed that help generously to their patients. Today, doctors have amazing medical resources,but they are limited in supplying them by scarcity and economics. How, for instance, do theydecide whether a patient gets a liver transplant? First, they have to determine if the patient is agood candidate for organ transfer. Then they have to locate a liver donor or apply to an organregistry. They also have to consider how the surgery will be paid for since they will needapproximately $100,000 to cover the expense.What should doctors do? Should they follow the market approach and allot treatment tothose who will pay the most for it? Should they decide on the basis of medical need? Shouldthey depend on a committee to make the decision? Should they depend on a lottery system or anHMO to make decisions regarding allocating treatment? Or should they follow the customaryapproach, which is a bunch of practices that mask the fact that treatment is being rationed? Eachof these approaches has its advantages and disadvantages.The market approach is consonant with the free market economy. It simplifies the choicebecause the transplant goes to those who can pay for it, either with their own money or withinsurance. Many libertarians feel comfortable with this idea because people would get the carethat they have earned and deserve. Many of us would be troubled if society followed this optionexclusively. It is, however, a component of the customary approach discussed below.The medical-need approach would allot organs by giving priority to patients who mostneed them to stay alive. It would be supported by a prognosis on the patient’s likelihood ofrecuperating to live a healthy life. According to medical need, a 93-year old man who wouldalmost certainly die with a transplant would have priority over a 30-year old woman who couldlive for six months without a transplant. According to medical prognosis, the woman wouldreceive the transplant.The lottery approach is another simple approach to rationing transplants that guarantees akind of fairness because it treats all seekers of expensive and scarce treatment equally. Thisapproach may be too simple because it does not take into account the seriousness of need, thelikelihood of success, the length of time on a waiting list, or the person’s age or importance totheir families and society. On the other hand, everyone would have an equal chance of receivingtreatment.The committee approach merely moves the decision making from a doctor to acommittee without dealing with underlying ethical concerns. The committee is likely to reflectthe arbitrary biases of its members. It does, however, distribute feelings of guilt and gives itsmembers a feeling of justification because one’s judgment is supported by one’s peers. Thecustomary approach, on the other hand, offers some comfort to the medical establishment. Itconceals the reality that people are denied treatment because of rationing and conceals reasons ofeconomics and bias that shape the rationing. In short, it does not rock the medical status quo.For these reasons, the customary approach will remain in place with only minormodifications until situations, interest groups, and individuals mount campaigns for moretransparency. This is the ordinary course of democracy: Elites make decisions for their ownbenefit until people make them decide for the benefit of ordinary people.One practical decision-making strategy for allotting organ transplants or other scarceand/or expensive procedures is an explicit or implicit checklist. Using such checklists, doctors,committees, and HMOs automatically disqualify certain groups of people from receiving them.Such people might be excluded on the basis of: age, criminality, drug or alcohol abuse, mentalillness, likelihood of medical failure, quality of life, low social standing, or lack of insurance.Carl Cohen (as cited in Card, 2004) argues that there are no special reasons that shouldautomatically deprive alcoholics of liver transplants, a position with which many Americansdisagree as evidenced by the furor that erupted when Mickey Mantle, an alcoholic, got a liverwhile those who had not been alcoholics went without. Daniel Callahan (as cited in Card, 2004)argues that scarce treatments should not be allocated to people who have completed theirproductive life spans because society owes people a good life, not a long life, and because givingold people those treatments will deprive younger people of opportunities for a full life. Hebelieves that old age is meant to be a time of reflection and making peace with inevitable death.George Annas (as cited in Card, 2004) considers ideas for deciding between prostitutes,playboys, poets, and other reprobates. He says the process should be “fair, efficient, andreflective of important social values” (p. 458). He believes that the initial screening should bebased exclusively on strict medical criteria. The secondary criteria should minimize social worthcriteria and move toward a randomized method of selection, for which he prefers a modified“first come, first served” procedure. For example, every prospective kidney recipient would firstbe typed with prospective donated kidneys on the basis of compatibility and likelihood ofsuccessful outcomes. After the first selection had been completed, the prospective recipient whohad been on the list the longest would be awarded the transplant.On controversial measures of distributive justice, such as the allocation of medicalresources, conflicting moral and economic stances prohibit our assuming any common moralconsensus. Rational ethical consensus needs to be constructed with careful attention to all pointsof view and the details of particular situations. General ethical considerations must be balancedagainst each other in making such decisions. For these reasons, an ethics committee composedof broadly represented stakeholders should probably be consulted in the allotment of scarcemedical resources. In such a committee, political considerations would either be sublimated toethical ones or, at least, would be balanced among competing interests.A doctor’s ethical decision making is more difficult in the United States than it is in theUnited Kingdom. The British National Health Service provides universal health care to allcitizens, but it makes explicit what medical procedures will not be supported. More elaborate xray,MRI, and Cat Scans are not supported, for example, under the justification that their costwould subtract from the care provided to the remainder of the population. In other words,medical resources are rationed. Of course, the middle class and wealthy can fly to countries suchas Belgium and receive any treatment they can afford to pay for, so health care is really onlyrationed for the working class and the poor.American doctors are pressured on both sides: by their patients to provide treatments ofquestionable worth and by HMOs and hospital administrators to limit the use of expensive testsand treatments. In the U. S. the cost-containment role is taken over by a number of organizationssuch as HMOs that pressure hospitals and doctors to limit expensive procedures. A doctor riskshis livelihood and practice if he or she continually orders tests and procedures that arediscouraged by HMO accountants. Doctors and hospitals are also financially rewarded if theyspend less than the amount set by the HMO. Thus by means of operant conditioning, they aretaught to provide their patients less service than might be appropriate. Some authors believe thatthis conditioning turns doctors into double agents who slight their patients in favor of HMOs andother institutions.In this connection, an Oklahoma study (Khalig, Broyles, & Robertson, 2003) found thatinsurance status, prospective payment, and the unit of payments make a difference in the lengthof hospital stays. Medicare-insured, Medicaid-insured, and the uninsured experiencesignificantly shorter episodes of hospitalization than their commercially insured counterparts.These shorter stays were found to contribute to physician-induced (iatrogenic) injury. This studyand many others argue that medicine in the United States needs to find a different method offinancing. Whatever happens, however, the chances are that, because of the progress in treatingchronic diseases and American’s high expectations, the cost of health care will continue to riseno matter who pays for it.Another reason that medical costs are high in this country is the American tort system.Premiums got so high in West Virginia because of the thousands of law suits against doctors thatphysicians staged a 1-day strike to protest. Worse, so many physicians have moved out of thatstate that people in some areas have to drive two or more hours to see a doctor. Two issues areimportant here. The first is the many unnecessary lawsuits that people bring against doctors,lawsuits that frequently cost insurance companies millions of dollars.On the other hand, doctors, like the rest of us, make mistakes. For example, if a doctorsews up after an operation and leaves a clamp inside the patient, what should he or she do?Ignore it and hope for the best? Wait until the patient reacts badly and then reopen? Cover upthe incident? Confer with lawyers to design a defense strategy? Consult with accountants to seeif his or her insurance premiums will skyrocket? Tell the patient and relatives what happened,apologize, reopen, and correct the mistake?Thurman (as cited in Card, 2004) says that the barriers to admitting mistakes are:1. The provider’s difficulty in confessing mistakes.2. The fear of implicating other providers.3. The possibility of liability exposure. (p. 484)The first barrier has psychological force but no ethical force. We all make mistakes, but ethicalpeople admit and correct them as quickly as possible. Honest admission of mistakes is cheaperthan cover-up because cover-up adds fraud to mere malpractice and angers the patient or family,who might then sue the doctor or hospital. Doctors are discouraged from speculating about thebehaviors and intentions of other providers. Instead, they should relate only their presentobservations of a patient and not assign guilt to anyone. Both the national and state legislaturesare currently struggling to find a solution to medical liability that is fair to both doctors and topatients who have truly been harmed. Some states, like New York and Pennsylvania, exempt“mere” medical malpractice from punitive damages.PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET AN AMAZING DISCOUNT ?
