Chapter 32

Introduction to Ethical Dilemmas in Healthcare

• Physicians must act in patients’ best interests.

• Conflicts arise when one patient’s needs limit another’s access to care.

• Limited resources (e.g., critical care beds, physician time) lead to ethical dilemmas.

• Allocation refers to funding decisions for healthcare programs (macroallocation), while rationing refers to limiting care for individuals (microallocation).

Societal Allocation Policies in the U.S.

• The U.S. lacks coherent societal allocation policies unlike other countries (e.g., Great Britain).

• Ethical question: Can physicians ethically ration care in the absence of clear societal agreements?

Case Study: Limited Coronary Care Beds

Patient Scenario

• Mr. H presents with chest pain; CCU and ICU are full.

• Two current CCU patients:

  • Patient A: Comatose, unlikely to survive

  • Patient B: Stable post-angioplasty, needs monitoring

Ethical Dilemma

• Transferring a stable patient might benefit Mr. H, who needs immediate care.

• Rationing decisions must consider the potential benefits for each patient.

Arguments Against Bedside Rationing

• Traditionally seen as unethical; physicians viewed as advocates for patients.

• Ethical fiduciary duty requires maximized patient benefit without cost considerations.

• Lack of agreed social priorities may lead to arbitrary and biased rationing decisions.

Arguments Supporting Bedside Rationing

• Rising medical costs necessitate limits on care decisions.

• Beneficence is not an absolute duty; prioritizing broader population health can be justified.

• Situational ethics may require acting against an individual patient's interests to benefit others (e.g., public health concerns).

Perspectives on Beneficence and Rationing

• The American Medical Association endorses advocating for care that materially benefits patients.

• Structured frameworks for resource allocation can promote fair rationing without explicitly naming it.

Rationing and Microallocation Decisions

• Treatment decisions should consider individual patient circumstances, as physicians often have more information than blanket policies.

• Informal rationing occurs as a standard practice in medical care.

Case Study: Rationing Due to Limited Physician Time

• Mr. M (possible MI) vs. an asthmatic patient both need attention but have no scheduled appointments.

• Physicians must prioritize based on clinical urgency.

Ethical Considerations

• Life-threatening scenarios take priority over stable conditions, balancing between emergency needs and scheduled care.

• General rules guide priorities, but individual interpretations are necessary for personalized care.

Rationing Based on Future Scarcity of Resources

Case Study: Shortage of Blood Products

• 36-year-old man with cirrhosis requires blood but uses resources that may be needed for trauma patients.

• Ethical implications of loyalty complicate decision-making for ongoing treatment vs. prospective patient care.

Drug Shortages and Institutional Policies

• Ethical frameworks should guide decisions in drug shortages rather than individual discretion to avoid biases.

• Standardized policies enhance consistency, ensuring fair treatment across patients.

Rationing Based on Cost

Case Study: Expensive Care for Low-Quality of Life

• Mrs. D, with severe dementia, requires dialysis with uncertain benefits, raising moral quandaries about resource allocation.

• Physicians feel conflicted due to financial implications of administering futile care.

Ethical Issues in Cost-Based Rationing

• Public policy in the U.S. does not permit individual physicians to ration care based on cost.

• This leads to disparities in treatment offerings based on various factors, including facility routines.

Institutional Recommendations for Physicians

• Suggestions for Ethical Rationing Decisions:

  • Seek more resources within the healthcare system.

  • Engage in open dialogue about rationing decisions.

  • Get multidisciplinary second opinions to enhance decision-making.

  • Inform patients or their surrogates when rationing care becomes necessary.

Summary

• Ethical rationing at the bedside is justified when it allows one patient to receive greater benefits than another receiving only marginal benefits.

• Rationing to save costs is less justifiable unless it redirects resources to higher priority care needs.

• Institutions should support consistent and equitable rationing practices.