Day 4 Session 3

Question 1

What are the three main steps to resource allocation?

Answer 1

1. Background - setting the outlines of the debate
   2 ethical approaches - to resource allocation at macro/meso level
   3 Examples of priority-setting - for resource allocation in health care

Question 2

What are the two ethical approaches?

Answer 2

1 The maximising approach - QALYs

2 The Distributive justice approach

Question 3

What are the levels of resource allocation? and what do they entail?

Answer 3

Macro-govt level 
-allocating federal health budget 
Meso - mid-level 
- Eg a hospital deciding what it should pend money on 
Micro - individual level 
- priority on waiting list & eligibility

Question 4

Is resource allocation a real ethical issue in health care?

Answer 4

Yes

Question 5

Whose values should be taken into account?

Answer 5

• impact values of economics
• social values
• ethical values

Question 6

What is the maximizing approach to resource allocation?

Answer 6

• the most bang for your buck
• based on moral theory of utilitarianism
• disregards justice as inherently important concept
• aims is to maximize good consequences in terms of health (not to produce fairness)

Question 7

What is QALY? and how is it used?

Answer 7

• used in maximising approach
  Questions to ask:
  1. How many patients will each one treat per year?
  2. What will be the health outcomes – how many QALYs?
  1. How many life-years gained?
  2. How much improvement in health (ie what quality of life
  is produced)?
  3. How much does each program cost?
  4. Which program produces the most health for the
  money?

Question 8

What are some factors that are not considered in basic maximizing approach?

Answer 8

• The pattern of distribution (doesn’t take into account disadvantaged)
• the level of need of suffering

Question 9

What are some implications of the maximising approach?

Answer 9

1. Elderly systematically (though not intentionally) lose out,
   since they have less years left to live.
2. The young are systematically (though not intentionally)
   favoured, since they have the greatest number of years
   still to live.
3. Favours preventive programs over acute health services –
   treatment in the last few months of life does not
   produce many QALYs. (ie those whose death is
   inevitable in short term systematically miss out)
4. It is argued that those with disabilities systematically lose
   out, since there is limit to their gain in health (it will
   never be 100%) – but this is disputed

Question 10

What is the ‘fairness’ approach: Distributive justice?

Answer 10

Consider:

• need
• contribution
• merit(desert)
• equal shares (egalitarianism)

Question 11

What is distributive justice? & the material principles?

Answer 11

how to share out a limited resource in a fair manner
-differs from criminal (how to respond to a person who has committed a crime), procedural (fair justice procedure) & material (people who get the resource ‘deserve is the most)

• need
• contribution
• merit(desert)
• equal shares (egalitarianism)

Question 12

What is the right way to allocate scarce resources according to the distributive justice approach?

Answer 12

Give it to the people who:
- need it most
- have the greatest contribution to the group
- deserve it the most just to their actions/character
OR - give it to everyone equally

• BUT depends what it is and how it’s used

Question 13

What counts as ‘need’ in the criteria for allocation?

Answer 13

• subjective (‘desires’, demand)
• Objective (basic requirements of life)
• > nearly impossible to judge
• severity
• suffering
• can get the best out of treatment

Question 14

What are the implications of using ‘need’ as a criteria for allocating health care resources?

Answer 14

• Concentrates resources on acute care, where the
  strongest needs are (preventing imminent death)
• Leaves out preventive health approaches, since there is no current need, at least in the straightforward
  sense
• Some who receive resources will not survive – so does not produce best outcomes
• Makes cause of medical need irrelevant (important for later in our discussion)

Question 15

What are the possible criteria for allocation?

Answer 15

• need
• merit
• equal shares

Question 16

What is the explanation for using ‘merit’ as a criteria? And who is considered of higher & lower priority?

Answer 16

Basic idea is that some people deserve higher or lower priority for health care, because of some feature of themselves or their illness.

• higher priory: the young, those willing to help their community, public service
• lower priority: elderly, smokers, substance abusers, convicted criminals, second attempt organ transplant

Question 17

What are the two contentious principles? related to merit as a criteria

Answer 17

“Fair innings” / ”natural lifespan”
– a reason not to spend money on increasing the
length of life of those 70+
“Self-caused need” / ”personal responsibility”
– a reason to give lower priority who choose to
act in ways that put their health at risk (smoking,
using drugs….)
-> widely disputed

Question 18

What is the explanation for using ‘equal shares’ as a criteria?

Answer 18

Giving everyone an equal share of health care services does not make good sense
Aiming that everyone has an equal amount of health
does make good sense

Question 19

Who’s principle is the egalitarian criteria based on?

Answer 19

On Rawls’ maximin principle
- Aim to improve the situation of those who are least well off, before improving the situation of those who are better off

Question 20

What are some implications to using the maximin principle?

Answer 20

• Do not focus on aggregate health outcomes per se (level
  of health for whole community); focus instead on minimising inequality in health between sub-groups of
  the population
• suggests money should be spent on providing equality, not just on producing health
• Priority would be given to improving the health of people who has the lowest health status, to bring them up to the
  level of the most healthy (eg indigenous health & remote areas)