Health Care Allocation

What Is “Health”?

What is “health”? Before we can understand what health care is, and people’s access to it, it is important for us to review the very definition of health. Our answer to this question will have implications on what we deem to be the appropriate health care resources available to individuals. Do preventative measures, enhancement procedures, and cosmetic surgeries get included in the basic health care provided to individuals? “What is health?” may sound like a simple question, and one so straightforward that it probably didn’t even occur to you that we hadn’t yet asked it. But like most “simple” questions that you might find at the beginning of any philosophy lecture, this one too is hardly as simple as it might seem. And, in fact, we need a working knowledge of “health” if we are going to create an acceptable policy for the delivery of health care. You might think that “health” is simply the state of being that people have when they are not ill. That seems simple enough. But then, keep in mind that in fact the question of what “counts” as an illness has changed and evolved over the years, meaning that a person with symptoms X at one time might be considered sick, whereas at another time might not be. Moreover, there are some questions about what counts as a disease at all. Some philosophers have argued that the problem arises because definitions that draw a line between “healthy” and “unhealthy” are in fact both descriptive claims about some “state” and also normative claims about what “counts” as “normal.” A famous and politically charged example from the history of medicine was the fact that homosexuality was considered a “disease,” and was not declassified as such until the 1970s by key psychiatric associations. In fact, health and disease are social constructs. That doesn’t mean that there aren’t underlying real causes for many things that are called disease, of course.

The point is that, in many ways, who counts as a normal human being and what counts as a normal state are “normative” questions, not a natural “fact”. Every community develops uses of language, and these uses evolve over the years. The way that the community uses words reflects their beliefs and shapes their behavior. If condition X counts as “abnormal,” then it becomes something that needs to be “cured” or “removed.” Any agreement on a definition of health will thus be “framework-relative,” that is, calling something normal or abnormal presupposes that we share the same framework. What is “normal” or “healthy” in one cultural group may not be in another, and so on.

Here is a working definition you may have already encountered since it is the famous definition at the very beginning of the Constitution of the World Health Organization (WHO): “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Notice here that the WHO does not limit itself to “merely” biologically defined disease, but rather focuses on the overall “state” of the human in terms of physical, mental, and social “well-being.” The problem, from the outset, is that the notion of “well-being” is too ambiguous to end all debate. The point they seem to want to emphasize is that health is a quality of life, not a simple biological concept about proper functioning of the organism. We certainly can’t end this debate yet, but your aim should be to keep in mind that health can be less of a cut and dry concept that we might at first think that the stigma of calling something a disease is not merely unfortunate, but at least sometimes a result of underlying prejudices or stereotypes. In short, “health” cannot just mean “absence of disease”! For the purposes of this course, let’s work with this definition: take health in the spirit of the WHO definition with the important inclusion of the naturalist or scientific approach, understanding health to be “a state of generally good (if not optimal) physical and mental functioning of a person making possible their well-being within their environmental and social context, where ‘good’ is defined by the person in question and where the ‘social context’ is not unduly influencing that definition of ‘good.’” This definition is not perfect, but let’s keep it on the table as we proceed!

1. Health Care Allocation Definition

Let us turn now to the questions addressed more directly throughout your readings for this week, namely, allocation and right to health care. Now that we have a working definition of what health is, we can ask these two further questions: (1) is there a “right” to health (and thus to the care that would either ensure health or return us to health) and (2) what should be done in terms of allocation in the inevitable condition of scarcity? Allocation means the distribution of resources when there is some limited set of resources and various alternative or competing ways they could be allocated. For instance, in an exam you have a limited amount of time to complete the questions, and you are advised to allocate enough time to each answer (rather than using up all of your time on just one part of the exam!)

Macroallocation

Fisher notes at the outset that “allocation” can be subdivided into at least three levels: macroallocation (meaning “large-scale allocation”) can be used to describe how governments divide overall resources between all of the services that they fund, from education to police forces to the military to public works and infrastructure to the health care system. Almost every government will have to make tough decisions on how to direct their tax revenue to best serve the population.

Mesoallocation

At the medium level there is “mesoallocation,” such as when a regional health board must decide how much of their funding goes to each hospital, or when a hospital must decide on how to distribute funding between various units. Each hospital and each unit could always use more funding, and will also battle for at least a certain minimum beneath which they cannot function, yet rarely do regional boards or hospitals have enough for every service to receive all that it needs.

Microallocation

And at the lowest or most direct level, there is “microallocation,” where health care professionals (HCPs) must decide between individual recipients of care, such as who gets the only available liver transplant, or who is first in line for the MRI machine. In fact, most writers tend to only distinguish between micro and macro, but it is good to keep in mind that there are also many layers and levels to distribution of resources at the “meso” level.

Summary

The discussion has a natural movement from top to bottom, meaning that we must first have a macro distribution in order to then decide upon a micro distribution. If the macro (or meso) levels don’t actually fund the transplant unit in a hospital, preferring to focus on other services that will perhaps help more patients at lower cost, then it makes no sense to worry about who gets the kidney transplant, since there will be no kidney to transplant. But, it also works upwards, since the macroallocation should be guided by what the individual patients have a “right” to receive!

1. The Right to a Decent Minimum of Health

2. “The Right to a Decent Minimum of Health” by Allen E. Buchanan (Part 1 of 4)

In the first article for this lesson, Allen Buchanan addresses precisely the question of health. He suggests that a general consensus can be found on a claim that every person has a right to a “decent minimum” of health care, but that disagreement arises over what counts as a “decent minimum” and over whether there is a right to a more extensive level of care. He makes an important point that any justification of there being a right to a decent minimum must be tied to a more general theory of justice, and that merely knowing about the concept is probably not going to be enough.

3. “The Right to a Decent Minimum of Health” by Allen E. Buchanan (Part 2 of 4)

An example might help with this point. You might think that everyone should have the “right” to free speech. If you then study the concept of “free speech,” you will be able to say several things about it. But merely knowing the concept will not tell you why everyone should have this right. You would need to have a more general theory about human beings and the structure of a just society that would justify this “right.” That is, knowing what “free speech” is does not necessarily give us a reason to think it is a “right.” Only the underlying theory can do this. The same is true, suggests Buchanan, with the concept of a “decent minimum.” Knowing what a “decent minimum” is does not necessarily give us a reason to think that we have a “right” to it! © 2 © May not be copied or duplicated without the permission of the owner. Of course, as any of you in political science or who have taken courses in political philosophy know, there is no final agreement yet on “the correct” theory of justice! But remember, in applied ethics we must proceed as best we can—this is precisely what Buchanan hopes to achieve in his article.

4. “The Right to a Decent Minimum of Health” by Allen E. Buchanan (Part 3 of 4)

Now, is a “decent minimum” of health care a “right”? First, a “decent minimum” must be understood in relation to the society in question. That is, there is no “universal” decent minimum, since any minimum must be relative to the actually available resources in the community in question. The “decent minimum” in Canada, for instance, cannot be expected in a developing country, and vice versa. Where a “decent minimum” seems too low, there might be a moral argument for foreign aid or further restructuring of the government’s macroallocation.

5. “The Right to a Decent Minimum of Health” by Allen E. Buchanan (Part 4 of 4)

Secondly, a “decent minimum” seems to indicate that all (regardless of income level) should have access to a certain level of care, while leaving it an open question as to whether either better or faster care should also be for sale on an open market model. That is, should everyone be forced to take just the decent minimum? Finally, this indicates that “decent” must be defined; that is, what counts as “decent” for a good or tolerable life? This introduces again a normative evaluation into the very notion of health. I recommend reviewing the subtle arguments that Buchanan offers for why a decent minimum has some justification through a theoretical grounding via the various arguments he explores at the end of his article.

1. The Canada Health Act 2. The Canada Health Act (Part 1 of 6)

It is probably a fair statement that the majority of Canadians currently believe that persons have a right to a “decent minimum” of health care. Although many Canadians now feel that the Canadian national health care system (known as Medicare) is a defining part of Canadian society, it is not in fact that old of a system. Canada debated on a national scale the merits of a national health care system for decades before adopting the Canada Health Act in 1984.

3. The Canada Health Act (Part 2 of 6) The Government of Canada information on the act reads as follows: “Canada's national health insurance program, often referred to as "Medicare," is designed to ensure that all residents have reasonable access to medically necessary hospital and physician services, on a prepaid basis. Instead of having a single national plan, we have a national program that is composed of 13 interlocking provincial and territorial health insurance plans, all of which share certain common features and basic standards of coverage. Framed by the Canada Health Act, the principles governing our health care system are symbols of the underlying Canadian values of equity and solidarity.”

4. The Canada Health Act (Part 3 of 6)

In fact, the Canada Health Act enshrines in law the primary objective of Canadian Health Care policy to be “To protect, promote, and restore the physical and mental wellbeing of residents of Canada and to facilitate reasonable access to health services without financial or other barriers.”

5. The Canada Health Act (Part 4 of 6)

There are many things to be said for the success of the Canadian health care system, though it is certainly not without its critics. One key point that is often raised against the system is the perception that Canadian patients are forced to linger in long wait-times for services that would be faster if available for private purchase, such as in the United States. © 2 © May not be copied or duplicated without the permission of the owner. You will often hear people assert that Medicare is unsustainable and that patients are suffering because of wait times. However, although it may seem intuitive that faster care equals more effective care, having to wait for treatment does not necessarily mean that one’s health is being adversely affected.

6. The Canada Health Act (Part 5 of 6)

The fear that waiting for treatment will mean one’s health is being put at risk is further exploited by an argument that by allowing those who want to pay to get private service, they will be, so to speak, “out of the line,” making the public lines shorter. In fact, statistics cited by the Canadian Health Coalition indicate that because setting up a parallel “for profit” system removes physicians from the public system, often waittimes actually increase in the public system. Moreover, the for-profit system would in fact select the Easier-to-treat cases, leaving the most expensive patient issues to the public system, further draining the system. Studies also show that for-profit systems are less safe, because there is a pressure on profit rather than quality control and safety.

7. The Canada Health Act (Part 6 of 6)

And finally, the argument is made that health care should not be distributed based on ability to pay, but rather based on need. I don’t want to presume to settle this debate, and it will surely continue. But as a critical thinker, you need to be careful not to simply accept intuitions as facts. The big one here is fueled by fear that wait-times are killing patients. In Canada, every effort is made to prioritize emergency care and to “triage” patients who need immediate attention, while those whose medical outcomes will not be affected are required to wait. The system, that is, is not simply first come, first served. There may be good arguments for and against public or private systems, but you need to be careful to think as clearly as possible about the facts.

1. Why Undervaluing "Statistical" People Costs Lives

2. “Why Undervaluing ‘Statistical’ People Costs Lives” by Tony Hope Overview (Part 1 of 3)

Let’s now explore Tony Hope’s article in which he leads us to consider moral conflicts in health allocation. Please make sure you read the article before proceeding to finish this component; without reading the article, you will not be able to fully understand the arguments. A lot of times in practical ethics, we have to make tough decisions that will lead to undesired consequences. Moreover, sometimes no matter how we decide, the consequences are not satisfactory. With limited health care resources, we cannot always provide the best imaginable treatment to anyone who needs it. We will have to make decisions when facing conflicts like this. Hope cites a passage from the founder of consequentialist philosophy J. S. Mill. “Whether happiness be or be not the end to which morality should be referred—that it should be referred to an end of some sort, and not left in the dominion of value feeling or inexplicable internal conviction, that it be made a matter of reason and calculation, and not merely of sentiment, is essential to the very idea of moral philosophy…”

3. “Why Undervaluing ‘Statistical’ People Costs Lives” by Tony Hope Overview (Part 2 of 3)

As mentioned, if the best treatment cannot always be provided, then choices have to be made. As a matter of fact, new and better treatments are being developed all the time all over the world; in the United Kingdom (UK), where the author is from, about three new medicines are licensed each month. It is, however, not possible to provide these expensive treatment in clinical trials to everyone who might need them. How should we choose? © 2 © May not be copied or duplicated without the permission of the owner. Hope emphasizes a point many neglect—the quality of life in addition to life expectancy. There are certain treatments that are more effective in extending a patient’s life but do not drastically improve a patient’s quality of life. There are also treatments that may only extend a patient’s life for a few years but drastically increases the quality of life in those years. This is certainly something we should consider.

4. “Why Undervaluing ‘Statistical’ People Costs Lives” by Tony Hope Overview (Part 3 of 3)

However, going forward, Hope will focus exclusively on the extending of patient’ life for the arguments’ sake in the paper. Hope then argues that when we have to choose, the total number of years an intervention can extend amongst many patients is more important to consider, than how those years are distributed amongst various patients—namely, that we should choose an intervention that brings 35 years for 10 people in total than an intervention that extends two patients’ lives for 8 years each. The former gives 35 years in total and the latter only 16 years.

5. “Why Undervaluing ‘Statistical’ People Costs Lives” by Tony Hope The Rule of Rescue (Part 1 of 4)

Hope then goes on to consider what’s known as “The Rule of Rescue”; it is normally justified to spend more per life year gained in a situation where someone’s life is at high risk (e.g., being trapped in a mine, at sea, etc.) than in situations where we cannot identify who has been helped. In fact, the article started with such a case where the Australian government spent a great deal to save Tony Bullimore who was trapped at sea while attempting to sail around the world in 1997.

6. “Why Undervaluing ‘Statistical’ People Costs Lives” by Tony Hope The Rule of Rescue (Part 2 of 4)

Hope argues that it is not always justifiable to do whatever it takes to save an identifiable person, if we consider the rescuing service is simultaneously shutting doors to many others who need help—especially that the many others remain unnamed and only are reflected in statistics, doesn't mean they matter less than the clearly identifiable individuals.

7. “Why Undervaluing ‘Statistical’ People Costs Lives” by Tony Hope The Rule of Rescue (Part 3 of 4)

To argue that maximizing the years we can extend is still the principle we should adopt, and Hope gives a vivid example of a miner who gets trapped in a mine and is in need of rescue. A miner lies trapped following an accident. Without rescue, they will die. Given a sufficiently large rescue party, the miner can be saved. He asks, do you think you should join the rescue party if you faced a 1:10,000 risk of death in so doing?

8. “Why Undervaluing ‘Statistical’ People Costs Lives” by Tony Hope The Rule of Rescue (Part 4 of 4)

There are many issues that need to be considered here. If we do have a group large enough (let’s say 80,000) who join the team voluntarily, then we will statistically have about 8 people die from that mission even though as an individual who volunteers, one may think they are facing a very small risk. The commanding officer will surely be criticized for leading a rescue mission that results in more death than the death of the person who was originally in need of rescue.

9. “Why Undervaluing ‘Statistical’ People Costs Lives” by Tony Hope Health Care (Part 1 of 2)

What does this tell us about health care? It challenges certain practices and our default way of thinking. Say the UK government is making the society spend 50,000 pounds a year to keep a patient alive on renal dialysis while this money could have been used for patients with moderately raised cholesterol and face low but non-negligible risks of death resulting from heart attack. This may sound justified at first glance, and intuitive because we consider stopping the dialysis as a death sentence to the patient, while telling the patients with moderately raised cholesterol they face certain risks without treatment is not condemning them to death. They may not have a heart attack even without treatment after all. 4 © May not be copied or duplicated without the permission of the owner. However, when we take the statistic into consideration (let’s say every year, x out of 1000 persons died of moderately raised cholesterol) we thus know someone will die from untreated cholesterol problems, given that we know there are thousands of patients with raised cholesterol out there.

10. “Why Undervaluing ‘Statistical’ People Costs Lives” by Tony Hope Health Care (Part 2 of 2)

The conclusion is not that Hope thinks we should prioritize the treatment of high blood pressure over treatments like dialysis. Instead, the conclusion is that we need to consider “statistic death” and invest in not just the “rescuing measures” but also treatments that could prevent death in statistically significant ways. We should also consider the importance of treating relatively low-risk disease as well as preventative measures, and we should not naturally assume dire situations take priority over other health issues, especially when it affects a large scope of patients.

11. Wrap-Up

In this lesson, we discussed what is health, which is not an objective state as some might believe. We then talked about the basic forms of health care allocation, including macroallocation, mesoallocation and microallocation. We then discussed the ideas in the Canada Health Act. Following Allen Buchanan’s article, we talked about individuals’ right to a decent minimum of health, and lastly, we discussed the importance of statistics and the proper moral weight we ought to place on them, as each number reflects the lives of real people.

12. Knowledge Check: Introduction

Now that we are at the end of the lesson, please try to answer these questions. Again, whether you answer them correctly will not affect your grade in the class, but you will need to complete them for the unit to be marked as “complete.” If you have questions about them, don’t forget to bring them to the office hour, or ask your TA about them via email.