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Showing posts with label Rationing Care. Show all posts
Showing posts with label Rationing Care. Show all posts

Tuesday, November 28, 2023

Ethics of psychotherapy rationing: A review of ethical and regulatory documents in Canadian professional psychology

Gower, H. K., & Gaine, G. S. (2023).
Canadian Psychology / Psychologie canadienne. 
Advance online publication.

Abstract

Ethical and regulatory documents in Canadian professional psychology were reviewed for principles and standards related to the rationing of psychotherapy. Despite Canada’s high per capita health care expenses, mental health in Canada receives relatively low funding. Further, surveys indicated that Canadians have unmet needs for psychotherapy. Effective and ethical rationing of psychological treatment is a necessity, yet the topic of rationing in psychology has received scant attention. The present study involved a qualitative review of codes of ethics, codes of conduct, and standards of practice documents for their inclusion of rationing principles and standards. Findings highlight the strengths and shortcomings of these documents related to guiding psychotherapy rationing. The discussion offers recommendations for revising these ethical and regulatory documents to promote more equitable and cost-effective use of limited psychotherapy resources in Canada.

Impact Statement

Canadian professional psychology regulatory documents contain limited reference to rationing imperatives, despite scarce psychotherapy resources. While the foundation of distributive justice is in place, rationing-specific principles, standards, and practices are required to foster the fair and equitable distribution of psychotherapy by Canadian psychologists.

From the recommendations:

Recommendations for Canadian Psychology Regulatory Documents
  1. Explicitly widen psychologists’ scope of concern to include not only current clients but also waiting clients and those who need treatment but face access barriers.
  2. Acknowledge the scarcity of health care resources (in public and private settings) and the high demand for psychology services (e.g., psychotherapy) and admonish inefficient and cost-ineffective use.
  3. Draw an explicit connection between the general principle of distributive justice and the specific practices related to rationing of psychology resources, including, especially, mitigation of biases likely to weaken ethical decision making.
  4. Encourage the use of outcome monitoring measures to aid relative utility calculations for triage and termination decisions and to ensure efficiency and distributive justice.
  5. Recommend advocacy by psychologists to address barriers to accessing needed services (e.g., psychotherapy), including promoting the cost effectiveness of psychotherapy as well as highlighting systemic barriers related to presenting problem, disability, ethnicity, race, gender, sexuality, or income.

Sunday, March 29, 2020

Who gets the ventilator in the coronavirus pandemic?

A group of doctors pictured during a surgical operation, with a heart rate monitor in the foreground.Julian Savulescu & Dominic Wilkinson
abc.net.au
Updated on 17 March 20

Here is an excerpt:

4. Flatten the curve: the 'too little, too late' approach

There are two wishful-thinking approaches that try to make the problem go away.

The first is that we need more liberty to impose restrictions on the movement of citizens in an effort to "flatten the curve", reduce the number of coronavirus cases and pressure on hospitals, and allow everyone who needs a ventilator to get one.

That may have been possible early on (Singapore and Taiwan adopted severe liberty restriction and seemed to have controlled the epidemic).

However, that horse has bolted and it is now inevitable that there will be a shortage of life-saving medical supplies, as there is in Italy.

This approach is a case of too little, too late.

5. Paternalism: the 'greater harm' myth

The second wishful-thinking approach is that some people try to argue that it is harmful to ventilate older patients, or patients with a poorer prognosis.

One intensive care consultant wrote an open letter to older patients claiming that he and his colleagues would not discriminate against them:

"But we won't use the things that won't work. We won't use machines that can cause harm."

But all medical treatments can cause harm. It is simply incorrect that intensive care "would not work" in a patient with COVID-19 who is older than 60, or who has comorbidities.

Is a 1/1,000 chance of survival worth the discomfort of a month on a ventilator? That is a complex value judgement and people may reasonably differ. I would take the chance.

The claim that intensive care doctors will only withhold treatment that is harmful is either paternalistic or it is confused.

If the doctor claims that they will withhold ventilation when it is harmful, this is a paternalistic value judgement. Where a ventilator has some chance of saving a person's life, it is largely up to that person to decide whether it is a harm or a benefit to take that chance.

Instead, this statement is obscuring the necessary resource allocation decision. It is sanitising rationing by pretending that intensive care doctors are only doing what is best for every patient. That is simply false.

The info is here.

Saturday, March 28, 2020

Hospitals consider universal do-not-resuscitate orders for coronavirus patients

Ariana Eunjung Cha
The Washington Post
Originally posted 25 March 20

Hospitals on the front lines of the pandemic are engaged in a heated private debate over a calculation few have encountered in their lifetimes — how to weigh the “save at all costs” approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.

The conversations are driven by the realization that the risk to staff amid dwindling stores of protective equipment — such as masks, gowns and gloves — may be too great to justify the conventional response when a patient “codes,” and their heart or breathing stops.

Northwestern Memorial Hospital in Chicago has been discussing a do-not-resuscitate policy for infected patients, regardless of the wishes of the patient or their family members — a wrenching decision to prioritize the lives of the many over the one.

Richard Wunderink, one of Northwestern’s intensive-care medical directors, said hospital administrators would have to ask Illinois Gov. J.B. Pritzker for help in clarifying state law and whether it permits the policy shift.

“It’s a major concern for everyone,” he said. “This is something about which we have had lots of communication with families, and I think they are very aware of the grave circumstances.”

Officials at George Washington University Hospital in the District say they have had similar conversations, but for now will continue to resuscitate covid-19 patients using modified procedures, such as putting plastic sheeting over the patient to create a barrier. The University of Washington Medical Center in Seattle, one of the country’s major hot spots for infections, is dealing with the problem by severely limiting the number of responders to a contagious patient in cardiac or respiratory arrest.

The info is here.

Friday, March 27, 2020

Coronavirus and ethics: 'Act so that most people survive'

Georg Marckmann
dw.com
Originally posted 24 March 20

Here is an excerpt:

Triage, a word used in military medicine, means classification. What groups do you classify the patients into?

There are several categories. Critically-ill patients are treated immediately, the treatment of seriously-ill patients is delayed, and patients who are slightly ill are treated later. Patients with no chance of survival receive purely palliative care.

The crucial element of situations involving a large number of sick people that we can no longer care for adequately is that we have to switch from a patient-centered approach to a group- or population-oriented approach. In a patient-centered approach, we try to adjust treatment as best we can to ensure the well-being of the individual patient and accommodate their wishes.

In a group-centered approach, we try to ensure that the incidence of illness and death within a population group is as low as possible. This places a strain on those making these decisions, because they're not used to it.

As a basic rule, we try to act in such a way that the largest number of people survive, because that is in the public interest.

The info is here.

Friday, March 8, 2013

Why the Ethics of Parsimonious Medicine Is Not the Ethics of Rationing

By Jon C. Tilburt and Christine Cassel
JAMA. 2013;309(8):773-774. doi:10.1001/jama.2013.368.

The ethics of rationing health care resources has been debated for decades. Opponents of rationing are concerned that societal interests will supplant respect for individual patient choice and professional judgment. Advocates argue that injustices in the current system necessitate that physicians use resources prudently on behalf of society, even in their daily work with individual patients. The debate is important, potentially divisive, and unavoidable.

Various groups have championed the cause of medicine practiced leanly, consistent with the professional responsibility to use resources wisely. These initiatives, which champion “parsimonious medicine,” have highlighted the 20% of routine practices in US medicine that add no demonstrable value to health care but that persist in the inertia and rituals of clinical work. The specialty societies and the Choosing Wisely collaborative outline commonsense principles for avoiding unnecessary, wasteful care.

Recent calls for waste avoidance and parsimonious care are not just a clever way to help physicians ration health care.  Despite the intuitive similarity between themes in rationing and waste avoidance, the ethical rationales underlying the two differ considerably.

The entire article is here.

Saturday, November 10, 2012

Caregiving as moral experience

By Arthur Kleinman
The Lancet
Volume 380, Issue 9853, Pages 1550 - 1551
3 November 2012


Everyone who has been in love or built a family knows that there are things, essential things, that money can't buy. Patients with serious illness and their network of caregivers know this too, because those things that really matter to us are threatened and must be defended. And many clinicians, reflecting on what is at stake in health care not only for patients but for themselves, know the same thing: the market has an important role in health-care financing and health systems reform, but it should not reach into those quintessentials of caregiving that speak to what is most deeply human in medicine and in living. This is the moral limit of an economic paradigm. Or at least it should be.

But we live in a truly confused age. The market model seems to have infiltrated so thoroughly into human lives and medicine that in certain circles—policy making and analysis, hospital and clinic administration, and even clinical work—economic rationality with its imperative of containing costs and maximising efficiency has come to mute the moral, emotional, religious, and aesthetic expressions of patients and caregivers. Most take it for granted and accept its implications. Models from economic psychology, behavioural economics, and business studies, based on the narrowest calculations of what a “rational” person would choose as most cost-effective, are now routinely applied to clinical decision making and the organisation of care.

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The great failure of contemporary medicine to promote caregiving as an existential practice and moral vision that resists reduction to the market model or the clarion call of efficiency has diminished professionals, patients, and family caregivers alike. It has enabled a noisy and ubiquitous market to all but silence different motives, ideals, hopes, and behaviours that must be expressed, because they are as much who we are as economic rationality.

The entire piece is here.


doi:10.1016/S0140-6736(12)61870-4

Wednesday, August 29, 2012

Rationing Health Care More Fairly

By Eduardo Portor
New York Times - Business Day
Originally published August 24, 2012

Older adults are understandably anxious about the political sniping over the future financing of Medicare. That is precisely the intention of the presidential campaigns.

Yet the cross-fire over who will cut Medicare by how much sidesteps a critical issue about the future of our medical care: If we must ration our care to hold down costs in the future, how can we do it in a fair, efficient and transparent way?

Mitt Romney’s campaign was brazenly misleading in its charge that the president’s health plan would cut medical services to older adults by reducing Medicare spending by $716 billion. The president’s savings will come mostly from smaller payments to managed care companies, which provide the same services as Medicare at a higher cost, and from slower growth in reimbursement rates to health care providers.

But the response of President Obama’s campaign also aimed to stoke voters’ fears. It stressed — rightly — that the plan to curb Medicare costs proposed last year by Representative Paul D. Ryan, Mr. Romney’s vice-presidential running mate, would add thousands of dollars to older Americans’ out-of-pocket expenditures. Yet it ignored Mr. Ryan’s recent efforts to soften the plan.

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Rationing is inevitable in a world with finite resources. We do it in this country, too, and it is still one of the least fair and most inefficient rationing systems in the world. You get care if you have the money to pay for it; if not, you probably won’t.

The wealthiest 30 percent of the population accounts for nearly 89 percent of health care expenditures, according to a government study. Tens of millions of Americans — those whose employers don’t provide health insurance, who are too poor to pay for it themselves and yet are too rich to use Medicaid — get the least health care of all.

Friday, June 1, 2012

From an Ethics of Rationing to an Ethics of Waste Avoidance

By Howard Brody, MD, PhD
The New England Journal of Medicine
Originally published on May 24, 2012

Dr. Howard Brody
Bioethics has long approached cost containment under the heading of “allocation of scarce resources.”  Having thus named the nail, bioethics has whacked away at it with the theoretical hammer of distributive justice. But in the United States, ethical debate is now shifting from rationing to the avoidance of waste. This little-noticed shift has important policy implications.

 Whereas the “R word” is a proverbial third rail in politics, ethicists rush in where politicians fear to tread. The ethics of rationing begins with two considerations.  First, rationing occurs simply because resources are finite and someone must decide who gets what. Second, rationing is therefore inevitable; if we avoid explicit rationing, we will resort to implicit and perhaps unfair rationing methods.

The main ethical objection to rationing is that physicians owe an absolute duty of fidelity to each individual patient, regardless of cost. This objection fails, however, because when resources are exhausted, the patients who are deprived of care are real people and not statistics. Physicians collectively owe loyalty to those patients too. The ethical argument about rationing then shifts to the question of the fairest means for allocating scarce resources — whether through the use of a quasi-objective measure such as quality-adjusted life-years or through a procedural approach such as increased democratic engagement of the community.

The entire story is here.

An interview with Dr. Brody is here.

Thanks to Gary Schoener for this lead.