Allocation Ethics
Allocation ethics is the investigation of the distribution of health-relevant resources with regard to ethical aspects. Such distribution questions arise, for example, in the case of organ donation or a shortage of medical resources in times of war or a pandemic. Allocation ethics is part of medical ethics . A distinction must be made between the terms rationalization, prioritization and rationing. There are different principles of allocation and it is controversial which one is fair in which situation.
Background in healthcare of modern industrial nations
In recent years and decades, life expectancy and, as a result, the consumption of resources in the healthcare sector has increased significantly. This is causing increasing problems with the financing of the health system. Medical services can probably no longer be financed in the future (and in some cases already today) for everyone who needs them. This reality collides with the solidarity principle, according to which all sick people should have the same opportunities for medical treatment and this should be available in sufficient quantities. In order to maintain a supply for everyone as long as possible, rationalization measures are applied. If these are not sufficient, which will sooner or later be the case, additional prioritization and possibly rationing must be carried out.
Rationalization, prioritization and rationing
Under rationalization (Health Care) are understood measures that efficiency and productivity as part of a service provision are aimed. Processes and procedures that are ineffective, less effective than cost-equivalent alternatives or not more effective than cheaper alternatives are to be identified and abolished. This should make it possible to increase the level of care with the same financial outlay or to maintain the level of care with less financial outlay.
If resources are scarce and not all patients can be cared for, criteria must be drawn up according to which a decision is made as to which therapy options are still available for which patients. Priority must be given to certain indications, patient groups or procedures over others. That is what is generally understood by prioritizing medical services .
When setting the prioritization criteria, a multilevel ranking is created in which methods, illnesses, disease groups, care goals and indications are arranged in a ranking. A ranking can take place within a certain supply area (for example with regard to heart disease), this is called vertical prioritization. If different disease groups or care goals are placed in a context, this is a horizontal prioritization. Since it is often difficult from a political point of view to admit a deficiency and there is no consensus on suitable criteria, prioritization in reality is often intransparent. However, if the patient-doctor relationship is not to be destroyed and mistrust is not to be fueled, the decisions based on criteria must be transparent and understandable.
In medicine, one speaks of rationing for a coercive measure if goods or services or financial resources are so scarce that the objective need cannot be met. Rationing exists in an indirect and in a direct form: In primary rationing it is about that the state in the health care system is obliged to determine an appropriate share of the total expenditure for the health care system. This is often referred to as indirect rationing, since it is not a question of person-related but rather resource-related rationing. Secondary rationing, or the direct form of rationing, is about the allocation of funding to medical areas and, above all, the allocation of funds to patients. Due to the scarcity of resources, the doctor has to decide which funds can be guaranteed to a patient and which are withheld from him.
Allocation principles when medical resources are scarce
The following allocation principles are discussed in the literature: lottery, waiting list, need, age, survival prognosis, age prognosis, behavior, instrumental value, reciprocity and financing. All of them have advantages and disadvantages. The most important are listed in this table.
| principle | advantages | disadvantage |
|---|---|---|
| 1. Lottery: Distribution by lot. | Random principle: justice is fulfilled | Neither the minimization of the fatality nor the protection of the medical professionals is taken into account. |
| 2. Waiting list: prioritization according to waiting time. First come first serve. | No discrimination: justice is fulfilled. | You can't get the greatest benefit: no maximum cure because you also have to treat patients with little chance of survival. |
| 3. Need: prioritization according to need / severity of the disease. The sickest first. | Helps those who need help most. | Those with the most serious illnesses are also those with less chance of recovery (no maximum cure rate). |
| 4. Age: prioritization according to age. The younger ones first. | In principle, younger people have more years of life ahead of them, which could be secured by recovery. | Violates the prohibition of discrimination by giving older people less value. |
| 5. Survival prognosis: prioritizing those who are most likely to survive. | Patients who are believed to benefit most from treatment are treated (minimizing deaths). | The prohibition of discrimination is forcibly ignored, since the prognosis that takes place, for example, pays attention to age and chronic diseases. |
| 6. Prediction of life years: prioritization of those who have the highest probability of the greatest number of years of life | People who will benefit most from treatment in the long term are preferred. Longer lifetimes can do even more for society. | The principle of justice is violated (prohibition of discrimination): People are selected on the basis of their age. |
| 7. Behavior: prioritization of those who have not voluntarily shown risky behavior that has led to the health situation | People who are not responsible for their suffering are given preference | Not maximizing the cure rate. Treatment will be withheld from people with life-threatening injuries. Self-indebtedness difficult to assess. |
| 8. Instrumental value: prioritization of those who are necessary for maintaining medical care, etc. a. Doctors and nursing staff | In order to save as many lives as possible, it is necessary to maintain the medical system, which would collapse without nursing staff. | Places are being withheld from those who would have needed them more to survive and who would have been more likely to improve their condition through treatment. |
| 9. Reciprocity: prioritizing those who have previously made voluntary contributions to society | Reward for help provided. Incentive for people to make voluntary contributions. | Not maximizing the cure rate. Persons who are physically or mentally incapable of making such contributions are excluded from the offer (prohibition of discrimination violated) |
| 10. Funding: prioritizing those who pay more for treatment | Helps to maintain the health system financially. | The principle of justice is neglected. (Formal principle of justice: "Equal cases should be treated equally, and unequal cases should only be treated unequally insofar as they have morally relevant differences".) |
Individual evidence
literature
- Christoph Fuchs, Eckhard Nagel, Heiner Raspe (2009): Rationalization, rationing and prioritization - what is meant? Deutsches Ärzteblatt 106 (12), pp. 554–557.
- Persad G, Wertheimer A, Emanuel EJ (2009): Principles for allocation of scarce medical interventions. The Lancet 373 (9661): 423-31.
- Krütli P, Rosemann T, Törnblom KY, Smieszek T (2016): How to Fairly Allocate Scarce Medical Resources: Ethical Argumentation under Scrutiny by Health Professionals and Lay People. PLoS ONE 11 (7): e0159086. doi: 10.1371 / journal. pone.0159086